Columbia  ®mber!^it|>  ^^^. 

^cJjooI  of  Bcntal  antj  O^ral  burger? 


^tttvmtt  Hibrarp 


PSYCHOLOGICAL     MEDICINE 


Digitized  by  the  Internet  Archive 

in  2010  with  funding  from 

Open  Knowledge  Commons 


http://www.archive.org/details/psychologicalmedOOcrai 


PSYCHOLOGICAL 
MEDICINE 

A    MANUAL    ON    MENTAL    DISEASES    FOE 
PEACTITIONEES    AND    STUDENTS 


P7 

MAURICE   CRAIG 

M.A.,  M.D. (CANTAB.),  F.R,C.P.(LOND.) 

PHYSICIAN  FOR  AND  LECTDEER  IN  PSYCHOLOGICAL  MEDICINE,  GUY'S  HOSPITAL 

EXAMINER   IN  PSYCHOLOGICAL  MEDICINE  FOB  DIPLOMA  IN  PSYCHOLOGICAL 

MEDICINE,   CAMBRIDGE   UNIVERSITY 

EXAMINER  IN  PSYCHOLOGY  AND  PSYCHOLOGICAL  MEDICINE,  LONDON  UNIVEESITT 

LATE   CLINICAL  TEACHER  OF  PSYCHOLOGICAL  MEDICINE,   ROYAL  ARMY 

MEDICAL  COLLEGE,  LONDON 

LATE  SENXOB  ASSISTANT  PBYSIOIAN,   BETHLEM  ROTAL  HOSPITAL,  LONDON 


THIRD   EDITION 


WITH  27  PLATES,  SOME  IN  COLOUR 


PHILADELPHIA 

P.   BLAKISTON'S   SON   &   CO. 

1012   WALNUT   STREET 
1917 


n  V 


I   h 


i..  VI-  L 


^(^-^^^ 


-^•■Printed  in  Great  Britain. 


L'l'Vv'.lO'^  VA  T\.}JS.'d  ,' 


PREFACE 

TO 

THE   THIRD   EDITION 

As  almost  all  the  European  countries  have  been  involved  in 
war  for  the  past  two  and  a  half  years,  research  in  psychological, 
medicine,  like  many  other  studies  for  the  advancement  of  know- 
ledge, has  had  to  make  way  for  more  pressing  needs  ;  conse- 
quently there  has  not  been  as  much  new  work  to  embody  in  this 
edition  as  on  the  last  occasion.  Nevertheless  very  steady  progress 
is  being  made,  and  the  war,  entailing  as  it  has  done  great  strains 
upon  a  large  number  of  men  and  women,  has  been  the  means 
of  bringing  in  new  observers  who  are  opening  up  fresh  fields  of 
study,  and  consequently  the  great  developments  in  this  branch 
of  medicine  which  were  foreseen  and  referred  to  in  the  Preface 
to  the  Second  Edition  will  take  place  even  more  rapidly  than 
one  could  have  hoped.  A  new  era  in  the  study  and  treatment 
of  functional  nervous  diseases  is  beginning  ;  the  former  attitude 
towards  mental  disease  will  be  changed  ;  antiquated  terminology 
and  superstitious  beliefs  will  be  replaced  by  scientific  terms 
and  a  proper  understanding  of  the  subject.-  There  are  still  no 
facihties  for  the  treatment  of  poor  persons  who  are  showing 
signs  of  nervous  exhaustion  ;  these  continue  to  be  allowed  to 
drift  on  until  many  of  them  can  be  certified  as  insane.  Public 
opinion  is  beginning  to  appreciate  the  state  of  affairs  and 
will  shortly  demand  attention  to  this  matter. 

During  the  last  three  years  the  Mental  Deficiency  Act  has 
been  added  to  the  Statute  Book  and  it  is  fully  referred  to  in 
this  edition.  A  new  chapter  has  been  devoted  to  the  functional 
neuroses  and  psycho-neuroses  occurring  in  those  exposed  to 
the    stress    of    war.      Psycho-analysis    has  been    more    fully 


VI  PREFACE 

described  in  the  present  edition,  and  other  subjects  have  been 
added  to  and  brought  up  to  date. 

Once  again  I  have  to  express  my  grateful  thanks  to  Colonel 
Mott,  Director  of  the  Laboratory  and  Pathologist  to  the 
London  County  Asylums,  for  supplying  me  with  most  of  the 
illustrations  found  in  this  book. 

To  my  Secretary,  Miss  Brameld,  I  owe  a  special  debt 
of  gratitude  for  her  careful  revision  of  the  proofs  and  the 
preparation  of  the  Index. 

M.  C. 

87  Habley  Street, 
April  1917. 


PREFACE 

TO 

THE   FIRST   EDITION 

The  object  of  tins  book  is  to  lay  before  the  student  a 
short  account  of  the  principles  and  practice  of  Psychological 
Medicine.  Several  years  of  teaching  have  fully  convinced  me 
that  for  his  future  usefulness  the  student  must  be  thoroughly 
taught  the  underlying  principles  of  disease,  whether  that 
disease  falls  within  the  province  of  Medicine  or  Sm'gery.  It  is 
not  sufficient  to  know  that  certain  symptoms  will  be  found  to 
exist  in  certain  maladies  ;  the  cause  of  their  presence  and  their 
relative  importance  are  subjects  requiring  intelligent  study. 

The  keen  and  thoughtful  observer  will  succeed  in  healing 
disease  when  a  superficial  physician  fails,  although  the  latter 
may  have  a  thorough  knowledge  of  his  bookwork.  Once  the 
fundamental  principles  of  insanitj^  have  been  learnt,  the 
disorders  of  mind  will  at  least  be  intelligible,  and  no  longer 
a  mere  concatenation  of  strange  symptoms. 

Throughout  the  foUo"v\dng  pages  the  student  will  be  con- 
stantly reminded  to  look  upon  Inental  disorders  in  the  same 
way  that  he  views  disease  in  general.  This  warning  is  very 
necessary,  as  so  many  men  regard  the  insane  as  if  they  were 
the  victims  of  some  strange  visitation,  and  not  sufferers  from 
ordinary  illness. 

Antiquated  terms,  such  as  '  mad  '  and  '  lunatic,'  are  strongly 
condemned,  and  are  never  used  in  this  book,  except  when 
quoting  Acts  of  Parliament  or  legal  authorities.  The  retention 
of  these  words  is  harmful  in  many  ways  and  retards  progress. 
It  IS  therefore  incumbent  on  the  physician  not  only  to  discon- 
tinue using  them  himself,  but  to  discountenance  the  employ- 
ment of  them  by  others. 


VUl  PREFACE 

I  have  not  cited  cases  illustrative  of  the  various  disorders ; 
to  have  done  so  would  have  made  the  book  more  cumbrous, 
with  no  commensurate  advantage.  The  descrijjtion  of  isolated 
cases  may  be  very  misleading,  disorders  being  largely  coloured 
by  the  individual  characteristics  of  the  patient. 

I  have  also  decided  not  to  reproduce  photographs  of  patients 
suffering  from  various  diseases.  In  the  majority  of  instances 
it  is  impossible  to  give  a  typical  photograph  of  a  sufferer 
from  anj^  disease  until  that  disease  is  confirmed.  The  earliest 
symptoms  of  mental  disorders  rarely,  if  ever,  show  themselves 
by  changes  in  the  facial  expression  or  attitude  of  a  patient. 
Photographs,  therefore,  do  not  assist  the  diagnosis  of  mental 
disorders  in  their  earliest  forms,  the  point  upon  which  I  desire 
to  lay  especial  stress.  It  is  during  the  initial  stages  that  disease 
lends  itself  most  readily  to  treatment.  Unfortunately,  the  early 
symptoms  of  mental  disorder  are  commonly  overlooked,  as 
frequently  neither  the  physician  nor  the  laity  attach  sufficient 
importance  to  slight  changes  of  character  or  symptoms  of 
nervous  fatigue.  The  question  of  treating  minor  symptoms, 
such  as  restlessness  and  irritability,  is  a  point  to  which  the 
reader  should  give  attention. 

As  regards  the  general  scheme  of  the  book,  an  attempt 
has  been  made  to  meet  the  requirements  both  of  the  general 
practitioner  and  of  the  student. 

The  opening  chapter  is  devoted  to  a  short  description  of 
normal  psychology,  as  it  is  difficult  for  a  physician  to  investi- 
gate or  accurately  gauge  symptoms  of  the  diseased  mind  if  he 
is  totally  ignorant  of  normal  mental  processes. 

No  new  classification  of  insanity  is  olTered,  but  I  have 
endeavoured  to  hold  an  even  balance  between  the  old  and 
the  new  school  of  Psychiatry,  If  we  cannot  accept  the  whole 
of  Kraepelin's  classification  of  mental  disease,  we  can  by  no 
means  ignore  it,  forming  as  it  does  the  most  important  contri-- 
bution  of  recent  years  to  the  literature  of  insanity.  I  do  not 
disguise  from  myself  the  many  imperfections  of  my  attempt 
at  readjustment,  but  crave  the  clemenpy  of  the  critics 
on  the  ground  that  the  remodelling  of  old  ideas  is  ever 
difficult. 

A  chapter  has  been  devoted  to  the  subject  of  law  in  its 
relationship   to   insanity,   and  matters  such   as  testamentary 


PREFACE  ix 

capacity    and    criminal    responsibility    have    been    especially 
dealt  with. 

As  sleeplessness  is  both  a  frequent  caase  of,  and  an  im- 
portant symptom  in,  most  forms  of  mental  disorder,  a  chapter 
has  been  reserved  for  its  consideration. 

The  subject-matter  throughout  the  book  has  been  broken 
up  into  sections  for  the  benefit  of  those  who  wish  to  refer  to 
special  matters  only. 

This  book  is  designedly  simple  in  both  arrangement  and 
language,  and  is,  to  a  great  extent,  a  summary  of  many  years' 
asylum  experience  digested  for  the  student.  If  it  in  any  way 
helps  the  student  to  a  better  understanding  of  insanity,  or 
assists  the  general  practitioner  in  the  early  diagnosis  and 
treatment  of  mental  disorder,  it  will  have  fulfilled  its  purpose. 

I  owe  my  gratitude  to  many  friends,  who  have  given  me 
invaluable  assistance.  To  Dr.  F.  W.  Mott,  Director  of  the 
Laboratory  and  Pathologist  to  the  London  County  Asylums, 
I  am  deeply  indebted  for  supplying  me  with  most  of  the  illus- 
trations found  in  this  book  ;  and  also  for  his  many  kind  sugges- 
tions and  ever  ready  help.  I  accord  my  thanks  to  the  members 
of  the  Asylums  Committee  of  the  London  County  Council 
for  their  kindness  in  allowing  me  to  reproduce  several  illustra- 
tions from  the  '  Archives  of  Neurology.'  I  am  also  under 
no  small  obligation  to  my  friend  and  former  colleague.  Dr.  E, 
Goodall,  Medical  Superintendent  of  the  Joint  Counties  Asylum, 
Carmarthen,  not  only  for  the  loan  of  several  photomicrographs, 
but  also  for  his  kindly  assistance  in  the  reading  of  a  large  portion 
of  the  manuscript,  and  for  many  useful  suggestions  and  correc- 
tions. To  my  brother,  Norman  Craig,  barrister-at-law,  I  am 
indebted  more  than  I  can  well  express  for  devoting  much  time 
and  thought  to  the  revision  and  correction  of  the  whole  manu- 
script. I  also  owe  my  grateful  thanks  to  my  colleague.  Dr. 
Stoddart,  for  several  kind  suggestions,  and  to  Dr.  J.  S.  Bolton 
and  Dr.  G.  Watson  for  the  very  kind  loan  of  microscopic 
preparations  and  photomicrographs. 

M.  C. 

March  1905. 


CONTENTS 


CHAP.  PAQE 

Pbefaoe       .  .  .  .  , .V 

I.  NoBMAL  Psychology 1 

II.  What  is  Insanity  ? .19 

III.  Causation  of  Insanity  .         .         .         .         ,         .         .     .      26 

IV.  Classification  of  Insanity .39 

V.  General  Symptomatology       .......      45 

VI.    Mania 99 

VII.    Melancholia  and  States  of  Depeession        .        .         .     .     115 

VIII.     Stupor .133 

Catatonia 138 

[IX.    Chronic  Delusional  Insanity  (Paranoia)  ...     141 

X.    Dementia  PB^aEOox .     .    156 

XI.    Secondary  Dementia 166 

Organic  Dementia         ......         .     .     170 

XII.    Epochal  Insanities  : 

Puerperal  Insanities 173 

Climacteric  Insanity .181 

Senile  Insanity  and  Abtbeiopathio  Dementia        .     .     186 

XIII.    Intoxication  Psychoses: 

Alcoholism 196 

KoBSAKOw's  Disease 213 

mobphinism 214 

cocainism 218 

Plumbism 220 

XIV.  Gbneeal  Pabalysis  of  the  Insane  (Dementia  Pabalytica)      222 

XV.  Exhaustion  Psychoses  : 

Nbbve  Exhaustion  and  Nbubasthenia  ...    254 

Anxiety  Nbubosis 260 

Acute  Hallucinatory  Insanity        .....     260 
zi 


Xll 


CONTENTS 


CHAP. 

XVI.    General  Neuroses  : 

Epilepsy  and  Insanity 
Hysteria  and  Insanity  . 

Traumatic  Neuroses  , 

XVII.    Psyohasthenia  and  Obsessions 


XVIII. 


The  More  Common  Neuroses  :     Psycho-neuroses  occur- 
ring IN  Men  exposed   to  Shell   Shock  and  Strain 


265 

277 
287 

293 


XIX. 

UJJ-     VVAU            ...... 

Insanity  and  Physical  Diseases  : 

.          .           .     ouu 

Phthisis  and  Insanity  .... 

312 

Diabetes  and  Insanity 

.     315 

Influenza  and  Insanity 

.      .     315 

Chorea  and  Insanity 

.     317 

Insanity  of  Myxcedema 

.      .     320 

Exophthalmic  Goitre 

.     324 

Cretinism 

.      .     325 

Gout  and  Insanity    .... 

.     328 

Rheumatic  Fever  and  Insanity    . 

.      .     330 

Heart  Disease  and  Insanity    . 

.     331 

Sunstroke  and  Insanity 

.      .     331 

Malaria  and  Insanity 

.     332 

Syphilis  and  Insanity  .... 

.      .     332 

XX. 

Defective  Mental  Development  : 

Idiocy  and  Imbecility 

.     340 

Moral  Imbecility  .        .'        . 

.      .     364 

XXI. 

Feigned  Insanity    .         .         .         .         . 

.     373 

XXII. 

The  Relationship  op  Insanity  with  Law    . 

.      .     380 

XXIII. 

Sleeplessness  

.     400 

XXIV. 

Case-taking 

.      .     412 

XXV. 

Treatment'      ..... 

.           .433 

INDEX 

.      .     479 

Plates  I.  and  II.     .....         .     between 

pages  164  and  165 

jj 

III.— XXVII 

f  252  and  253 

PSYCHOLOGICAL   MEDICINE 


CHAPTEE   I 

NORMAL    PSYCHOLOGY 

Although  it  may  be  outside  the  province  of  a  treatise  on 
Mental  Diseases  to  discuss  Psychology  and  Psychological  Pro- 
blems, nevertheless  it  must  be  helpful,  if  not  absolutely  neces- 
sary, for  the  student  to  Imow  something  of  the.  workings  of 
the  normal  mind  in  seeking  to  understand  the  mind  which  is 
disordered.     For  this  reason  a  few  preliminary  pages  may  be 
usefully  devoted  to  a  brief  review  of  normal  mental  processes. 
Mind  is  composed  of  processes  which  are  constantly  changing, 
therefore  the  '  ego  '  of  one  moment  is  not  the  '  ego  '  of  the 
next.     It   is   this   constant   and  rapid   changing  that   makes 
the  study  of  mind  so  difficult.    Further,  a  mental  process 
is   purely  subjective,  whereas   processes   dealt  with   by  other 
sciences  are  largely  objective  and  can  form  part  of  the  experi- 
ence of  others.     Psychical  and  physical  processes  are  intimately 
connected,  and  our  study  of  mind  is  largely  assisted  by  observ- 
ing its  influences  on  the  body.     For  centuries  philosophers 
and  scientists  have  from  time  to  time  promulgated  various 
theories  as  to  the  relation  of  mind  and  body.     There  are  the 
ideahsts,  who    make  body  dependent  upon  mind  ;  and    the 
materialists,    who    postulate    that    mind    is    dependent    upon 
matter.    But  the  psychologist  of  to-day  prefers  not  to  dog- 
matise in  either  direction,  and  the  theory  of  psychophysical 
parallelism  is  that  which  is  largely  held.     This  theory  neither 
makes  mind  dependent  upon  matter,  nor  the  body  dependent 
upon  mind,  but  states  that  throughout  life  there  is  a  chain  of 

1 


•2  PSYCHOLOGICAL  MEDICINE 

psychical  events  which  runs  parallel  to  another  chain  of  phy- 
sical events.  Others  hold  the  theory  of  inter-actionism,  in 
which  it  is  believed  that  inter-action  takes  place  between  the 
spiritual  or  mental  processes  and  those  which  are  material 
or  nervous.  The  close  relationship  between  mind  and  body  is 
evident  to  all  observant  physicians.  There  is  a  mental  aspect 
to  all  physical  disease  ;  but  this  mental  aspect  is  too  frequently 
overlooked,  wdth  consequent  failure  to  recognise  a  symptom 
the  treatment  of  which  would  tend  greatly  to  the  relief  of  a 
patient.  The  mental  depression  with  gout,  and  the  hopefulness 
of  a  patient  with  phthisis,  are  symptoms  which  are  apparent 
to  the  most  careless  of  observers.  On  the  other  hand,  how 
frequently  we  see  such  a  symptom  as  the  irritability  of  fatigue, 
so  often  an  indication  of  the  approach  of  more  serious  trouble, 
either  misconstrued  or  overlooked. 

In  the  same  way,  if  due  attention  were  given  to  such  physical 
changes  as  loss  of  weight  and  irregularities  of  the  action  of  the 
bowels  in  unstable  individuals,  much  mental  disorder  might  be 
averted.  For  the  moment  it  is  enough  to  impress  upon  the 
reader  that  the  mental  aspect  of  the  organism  cannot  be 
separated  from  the  physical,  and  that  if  the  symptoms  of  the 
one  appear  to  be  more  urgent  than  the  other,  the  lesser  must 
not  be  overlooked. 

Sensation. — '  Sensation  '  is  the  term  used  to  express  the 
most  elementary  of  all  conscious  processes,  and  is  the  result 
of  the  stimulation  of  some  bodily  organ.  Sensations  are  of 
two  kinds,  viz.  (1)  Special  sense  sensations,  (2)  Organic  sen- 
sations. The  former  are  due  to  stimulation  of  one  of  the 
special  sense  organs,  and  the  latter  are  sensations  w^hich  are 
derived  from  the  ]\Iuscles,  Tendons,  Articular  Surfaces,  Ali- 
mentary Canal  (hunger,  thirst,  nausea,  etc.),  and  the  Circu- 
latory, Respiratory,  and  Sexual  Organs. 

The  organic  sensations  differ  from  the  special  sense  sensa- 
tions by  being  more  diffusible  and  more  closely  connected  with 
the  feelings.  They  are  not  so  well  defined,  and  tend  more 
quickly  to  die  out  of  memor3^  The  attributes  of  sensation 
are :  (1)  Quality,  (2)  Intensity,  (3)  Duration,  and  (4)  Extent. 
Quality  is  the  attribute  by  which  we  distinguish  one  sensation 
from  another  ;  for  instance,  a  colour  is  always  the  same  colour 
no  matter    how  intense  or  for  what  lenath  of  time  it  lasts. 


NORMAL  PSYCHOLOGY  3 

I'urther,  every  sensation  differs  in  intensity,  and,  according 
to  Weber's  Law,  '  if  sensations  are  to  increase  in  intensity 
by  equal  amounts,  their  stimuli  must  increase  by  relatively 
equal  amounts.'  That  is  to  say,  the  intensity  of  a  stimulus 
must  increase  by  a  certain  definite  amount  before  any  appre- 
ciable difference  in  the  sensation  can  be  detected.  The  other 
attributes  of  sensation  apply  to  time  and  extent,  the  latter 
being  present  only  in  the  cases  of  sight  and  touch.  The  sense 
of  position  and  movement  is  largely  made  up  of  sensations 
derived  from  muscle,  tendons  and  articular  surfaces. 

Affection. — Affection  has  been  defined  by  Titchener  in  his 
'  Primer  of  Psychology  '  as  an  '  elementary  conscious  process 
which  may  be  set  up  by  the  stimulation  of  any  bodily  organ. 
There  are  only  two  affections,  (a)  Pleasantness,  (t)  Unpleasant- 
ness. To  quote  the  same  author  again  :  '  Now,  when  we  have 
in  consciousness  a  complex  process  composed  of  sensations 
and  pleasantness  or  unpleasantness,  and  when  the  affective 
side  strikes  us  more  forcibly  than  the  sense  side,  we  call  the 
total  process  feeling.' 

Affection  differs  from  sensation  in  several  ways.  The 
more  we  attend  to  a  sensation  the  clearer  it  becomes,  whereas 
if  we  direct  our  attention  to  an  affection  it  fades  at  once. 
Habituation  weakens  affection,  but  not  sensation,  for  we 
_find  that  after  weak  sensations  have  lasted  for  some  time 
they  may  even  become  painful.  Affections  which  have  been 
almost  unbearable,  in  course  of  time,  if  they  continue,  may 
be  scarcely  noticed  ;  this  is  especially  noticeable  in  disorders 
-such  as  melancholia.  Both  with  feeling  and  affection  there 
are  certain  bodily  changes  which  accompany  them.  They 
are  not  so  marked  as  the  changes  found  with  emotion,  but 
consist  of  alteration  in  the  state  of  pulse,  breathing,  bodily 
volume,  and  muscular  strength.  These  changes  clearly  show 
the  close  relationship  between  mental  and  physical  processes. 

Attention. — Attention  is  the  sustained  and  continued  con- 
centration of  the  mental  faculties  on  some  particular  object 
or  idea.  Mental  processes  do  not  all  flow  along  at  the  same 
level ;  some  we  encourage,  others  we  endeavour  to  inhibit. 
Thus  attention  consists  partly  of  reinforcement  and  partly  of 
inhibition.  The  perceptions  which  we  encourage  become 
clearer,  last  longer,  and  are  more  useful.     Among  the  bodily 


4  PSYCHOLOGICAL  MEDICINE 

aspects  of  attention  we  find  that  the  muscles,  especially  of 
the  neck  and  eyeballs,  are  fixed,  expiration  is  prolonged,  or 
the  breath  may  be  held  altogether.  The  head  is  often  turned 
to  one  side  and  fixed.  Probably  the  tension  of  the  tendons  and 
muscles  in  action  largely  accounts  for  the  sensation  of  effort 
(Conation)  which  is  occasioned  by  active  attention.  Attention 
is  constantly  fluctuating,  and  cannot  be  fixed  for  more  than 
a  short  time  together.  The  range  of  attention  varies,  and 
although  probably  one  cannot  concentrate  the  mind  on  more 
than  one  complex  idea  at  a  time,  one  can,  as  has  been  shown 
by  experiment,  attend  to  several  simple  stimuli  at  the  same 
moment. 

In  addition  to  active  attention  there  is  a  state  of  passive 
attention,  at  times  spoken  of  as  instinctive  attention. 
Certain  things  have  to  be  attended  to,  whether  one  wishes  it 
or  not  ;  for  instance,  loud  sounds  or  bright  lights.  One  is 
largely  indebted  to  passive  attention  for  warning  of  any  sudden 
danger.  Attention  is  an  attribute  of  fairly  late  development. 
Some  cliildren  never  acquire  it,  and  at  all  times  it  is  easily  lost ; 
attention  fails  with  fatigue,  and  is  affected  in  all  forms  of  mental 
disorder.  Attention  is  the  basis  of  action,  for  in  the  primitive 
organism  without  attention  there  would  be  total  inaction. 

Conation. — Closely  connected  with  Attention  is  found  a 
condition  known  as  Conation,  or  Feeling  of  Effort.  All  con- 
sciousness is  more  or  less  conative,  but  some  states  of  con- 
sciousness are  far  more  conative  than  others.  In  prolonged 
active  attention  there  is  a  strong  feeling  of  effort.  Some 
authorities  beheve  conation  to  be  central  in  origin,  and  directly 
due  to  brain  activity  ;  others  hold  that  it  is  purely  the  result 
of  tension  and  strain  in  the  muscles  and  joints,  and  ^is  thus 
produced  by  peripheral  changes. 

Perceptions  and  Ideas. — By  origin  perceptions  and  ideas 
are  alike  ;  but,  for  the  sake  of  clearness,  a  distinction  between 
them  may  be  drawn.  Perception  may  be  spoken  of  when 
sensation  is  actually  aroused  by  the  presence  of  some  external 
stimulus  ;  idea,  when  the  mental  image  of  a  former  sensation 
is  intended.  For  instance,  I  see  a  book  in  front  of  me :  that 
is  a  percept ;  while  if  I  close  my  eyes  I  have  a  mental  record 
of  the  former  sensation  derived  from  seeing  the  book :  that 
is  an  idea. 


NORMAL  PSYCHOLOGY  5 

Perceptions  and  Ideas  are  divided  into  three  classes,  viz. 
(1)  Qualitative,  (2)  Extensive,  and  (3)  Temporal.  What  has 
been  said  of  sensations  can  be  said  of  perceptions,  so  far  as 
quaHty  is  concerned.  Further,  one  is  aware  of  locality  and 
position  ;  one  recognises  a  definite  arrangement  of  things  in 
space.  This  knowledge  in  early  life  is  largely  acquired  from 
tactual  sensation  ;  a  child  will  stretch  out  its  hand  to  reach 
things  far  beyond  its  grasp.  As  evolution  goes  on,  the  visual 
sense  develops,  and  in  adult  Hfe  it  is  on  this  sense  that  chief 
reHance  is  placed  for  information  as  to  size,  position,  and 
distance.  Binocular  vision  is  far  more  accurate  in  measuring 
the  third  dimension  than  monocular  vision.  There  is  no  inborn 
sense  of  the  position  of  things  in  space  ;  it  is  derived  from 
education,  and  by  such  data  as  the  size  of  the  object,  its  outhne 
and  distinctness,  the  uniformity  of  colouring,  by  the  accom- 
modation and  movement  of  the  eyes,  and  by  comparison  with 
surrounding  objects. 

Sterognosis  is  a  term  which  is  applied  to  the  perception  of 
form  and  consistency  as  derived  from  the  tactile  and  kin- 
sestbetic  senses.  This  sense  becomes  disordered  under  certain 
conditions. 

Rhythm. — Temporal  perceptions  and  ideas  include  rhytlim. 
Now  rhythm  is  found  to  accompany  both  mental  and  physical 
processes.  Sleeping  and  waking  occur,  or  ought  to  occur,  at 
regular  intervals.  Walking  is  rhythmical^  Marked  periodi- 
city is  present  in  the  reproductive  functions,  especially  in 
those  of  the  female.  Allusion  has  already  been  made  to  the 
fact  that  attention  waxes  and  wanes  :  it  does  so  in  a  rhythmical 
manner.  The  aesthetic  sentiment  is  found  to  favour  rhythm, 
as  is  shown  by  melody  and  dancing.  Ehythm  also  plays  a 
prominent  part  in  many  forms  of  mental  disorder.  The 
insanity  known  as  folie  circulaire  is  markedly  rhythmical. 
Dipsomania  and  other  impulsive  forms  of  mental  disease  may 
be  periodical  in  onset.  There  are  several  disturbances  of  the 
process  of  perception,  such  as  Illusions  and  Hallucinations, 
but  it  will  be  more  convenient  to  describe  them  in  a  subsequent 
chapter. 

Association  o£  Ideas. — Let  consideration  next  be  given  to 
Association  of  Ideas  ;  that  is  to  say,  the  tendency  of  every  idea 
to  bring  into  the  mind  its  associated  ideas.     This  may  occur 


6  PSYCHOLOGICAL  MEDICINE 

by  simultaneous  association  ;  a  presented  idea  may  bring  up 
without  any  appreciable  delay  another  idea.  Or  the  associa- 
tion may  be  successive,  as  instanced  by  reverie  or  train  of 
thoughts. 

The  association  of  ideas  plaj-s  a  far  larger  role  in  an  in- 
dividual's life  than  many  persons  appreciate.  If  it  were  not 
for  this  process  we  should  never  get  beyond  the  most  rudi- 
mentary state  of  thought  and  action.  This  power  of  associa- 
tion is  the  basis  of  habit,  and  habit  directs  and  dominates  om' 
whole  life. 

Habit. — Habit,  as  akeady  stated,  is  an  example  of  the  law 
of  association.  Broadly  speaking,  there  are  two  great  divi- 
sions of  habits  :  (1)  Those  wliich  are  inborn  in  us,  and 
which  may  be  looked  upon  as  instincts  ;  (2)  Those  which 
have  been  acquired  in  the  lifetime  of  the  individual.  It  is 
over  the  latter  that  v\-e  have  the  greatest  control.  Professor 
James  states,  '  The  phenomena  of  habit  in  living  beings  are 
due  to  the  plasticity  of  the  organic  materials  of  wliich  our 
bodies  are  composed.  Our  nervous  system  grows  to  the  mode 
in  which  it  has  been  exercised.  Habit  simplifies  the  move- 
ments to  achieve  a  given  result,  makes  them  more  accurate, 
and  diminishes  fatigue.'  Watch,  for  instance,  the  beginner 
leaiTing  to  play  the  piano  ;  at  first  the  energy  employed 
seems  to  spread  all  over  the  body,  but  the  more  easily  the 
special  movement  occurs,  the  shghter  the  stimulus  required  to 
produce  it  ;  and,  the  slighter  the  stimulus,  the  more  its  effect 
is  confuied  to  the  fingers  alone.  Dr.  Maudsle}^  puts  the  matter 
very  tersely  when  he  says,  '  If  an  act  becomes  no  easier  after 
being  done  several  times,  if  the  careful  direction  of  conscious- 
ness were  necessary  to  its  accomplishment  on  each  occasion, 
it  is  evident  that  the  whole  activity  of  a  lifetime  might  be 
confined  to  one  or  two  deeds — that  no  progress  could  take 
place  in  development — a  man  might  be  occupied  all  day  in 
dressing  and  undressing  himself ;  the  attitude  of  his  body 
would  absorb  all  his  attention  and  energy  ;  the  washing  of 
his  hands  or  the  fastening  of  a  button  would  be  as  difficult 
to  him  on  each  occasion  as  to  the  child  on  its  first  trial,  and 
he  would  furthermore  be  exhausted  by  his  exertions.'  Again  : 
'  Habit  diminishes  the  conscious  attention  with  which  our  acts' 
are  performed.'     We  automatically  learn  to  do  the  right  thing 


NORMAL  PSYCHOLOGY  7 

at  the  right  moment,  as  in  walking,  jumping,  fencing,  etc. 
but  we  may  also  learn  to  do  the  wrong  things  habitually  ! 

Once  again,  to  quote  Professor  James,  '  We  all  of  us  have 
a  definite  routine  manner  of  performing  certain  daily  offices 
connected  with  the  toilet  ;  our  lower  brain  centres  know 
the  order  of  these  movements,  and  show  their  sm'prise  if  the 
objects  are  altered  so  as  to  oblige  the  movement  to  be  made 
in  a  different  way.  But  our  higher  thought  centres  know 
hardly  anything  about  the  matter.  Few  men  can  tell  off- 
hand which  sock  or  shoe  thej^  put  on  first.'  I  cannot  tell  the 
answer,  but  my  hand  never  makes  a  mistake.  Now  in  action 
gi-own  habitual,  that  which  instigates  each  new  muscular  con- 
traction to  take  place  in  its  appointed  order  is  not  a  thought 
or  a  perception,  but  the  sensation  occasioned  by  the  muscular 
contraction  just  finished  (in  doing  a  thing,  if  one  fails  one 
often  has  to  start  again  at  the  very  beginning)  ;  a  strictly 
voluntary  act  has  to  be  guided  by  idea,  perception  and  volition 
throughout  its  w'hole  com'se.  In  an  habitual  action,  mere 
sensation  is  a  sufficient  guide,  and  the  upper  regions  of  the 
brain  and  mind  are  set  comparatively  free.  For  example, 
the  knitter  keeps  on  with  her  knitting,  even  while  she  reads 
or  is  engaged  in  a  conversation. 

Habits  we  must  form,  so  that  the  importance  of  forming 
right  ones  cannot  be  over-estimated.  Let  me  remind  you 
once  again  that  we  acquii'e  habits  by  means  of  actively  at- 
tending to  that  which  we  are  learning  ;  and,  having  ofttimes 
accomplished  it,  the  action,  mode  of  thought,  or  whatever  it 
may  be,  passes  out  of  the  realm  of  consciousness  and  becomes 
automatic.  Throughout  life  we  are  constantly  putting  by 
(packed  up,  as  it  w^re,  all  ready  for  use)  judgments  and  actions 
which  for  the  future  will  be  available  for  immediate  require- 
ments. Thus  again  you  will  see  how^  important  it  is  that 
these  bundles  of  habit  should  be  built  carefully  up  whilst  in 
the  conscious  stage  ;  for  once  they  pass  beyond  this  stage 
they  will  remain,  maybe  for  many  years,  as  attributes  for  good 
or  ill. 

The  importance  of  habits  cannot  be  over-estimated  and 
in  treating  mental  disorder  their  significance  is  constantly 
compelling  attention.  Take  sleep  :  it  is  largely  habit,  and  if 
confidence  be  lost  and  the  association  between  bed  and  sleep  be 


8  PSYCHOLOGICAL  MEDICIKE 

broken,  this  may  become  a  serious  obstacle  to  the  successful 
treatment  of  insomnia.  Similarly  delusions  of  persecution 
may  be  originated  and  confirmed  by  the  habit  of  treating  those 
around  us  with  suspicion.  The  emotions  should  be  kept  under 
control  and  any  "wide  sweeps  from  excitement  to  depression 
should  be  corrected.  The  physician  and  those  whose  work  lies 
in  the  training  of  the  young  should  never  forget  to  encourage 
the  development  of  good  habits  and  the  eradication  of  bad 
ones,  whether  in  the  matter  of  physical  functions  or  in  the  attri- 
butes of  mind.  And,  when  we  turn  to  disease,  it  must  always 
be  borne  in  mind  that  bad  habits  may  seriously  jeopardise 
the  chances  of  recovery  and  therefore  must  be  corrected,  for, 
as  we  shall  point  out  later,  bad  habits  may  be  formed  during 
the  illness  which  will  in  future  militate  against  the  patient's 
usefulness  in  life. 

Emotions. — Emotions  are  more  complex  than  feelings.  In 
the  former  the  organic  sensations  take  a  prominent  place  ;  so 
prominent,  indeed,  that  some  authorities  go  so  far  as  to  say 
that  organic  sensation  is  the  basis  of  emotion.  In  emotion 
the  same  bodily  changes  occur  as  in  the  case  of  feeling  ;  but 
in  addition  there  are  changes  in  the  secretory  organs  and  in 
the  involuntary  muscles.  The  surface  of  the  body  may  be 
bathed  in  perspiration,  the  mouth  may  be  dry,  and  the  eyes 
wet  with  tears.  Extreme  emotion  is  spoken  of  as  Passion,  and 
when  an  emotion  has  lasted  for  some  time  it  usually  calms 
down  into  a  mood,  which  denotes  a  weaker  emotive  state. 
The  feelings  and  the  emotions  are  a  useful  barometer  by 
which  the  mental  state  and  even  the  physical  condition  of 
individuals  may  be  judged.  Disturbance  of  the  emotions  is 
frequently  an  early  symptom  in  all  forms  of  disease,  whether 
bodily  or  mental ;  and,  in  some  insanities  the  symptoms  may 
be  chiefly  confined  to  emotional  alterations  ;  or  it  may  be  that 
the  affective  changes  are  the  concomitants  of  a  more  complex 
insanity. 

Sentiment. — A  sentiment  differs  from  an  emotion  in  that 
with  the  former  there  is  a  state  of  active  attention.  It  is  by 
this  means  that  we  judge  and  say,  '  This  is  right  or  wrong,' 
*  This  is  true  or  false.'  Belief  and  disbelief  are  common  forms 
of  sentiments,  and  it  must  not  be  forgotten  that  disbelief  is 
just  as  positive  a  state  as  belief.     Doubt  is  the  state  of  un- 


NORMAL  PSYCHOLOGY  9 

certainty  which  Hes  between  two  behefs.  In  such  a  condition 
as  that  of  folie  de  doiite,  which  will  be  considered  later,  it 
will  be  found  that  the  active  weighing  of  motives,  and  the 
fear  of  doing  wrong,  are  the  determining  factors  in  the  inaction 
of  a  fair  proportion  of  the  insane.  The  aesthetic  sentiment 
is  one  that  has  no  small  interest  to  those  who  have  to 
treat  the  insane,  for  it  undergoes  alteration  in  most  forms 
of  mental  disorder.  The  acute  maniac  is  often  decorated  to 
an  extravagant  extent,  and  as  a  rule  sees  beauty  in  objects 
which  in  sanity  he  would  condemn  as  vulgar  or  commonplace. 
Conversely,  the  melancholiac  will  deplore  that  things  which 
he  formerly  thought  beautiful  now  appear  gloomy  and  ugly. 
Untidiness  and  want  of  personal  cleanliness  are  characteristics 
of  many  of  the  insane. 

Instinct. — ^Instinct  is  purposive  action  without  foresight  or 
education,  and  instinctive  action  differs  from  reflex  action  in 
that  it  has  psychical  concomitants. 

Instincts  are  developed  for  the  benefit  of  the  race.  In  the 
lower  animals  instincts  rule  supreme  ;  but  m^an  is  also  pos- 
sessed of  instincts  probably  even  more  than  animals.  The 
two  fundamental  instincts  are  desire  to  live  and  desire  to 
reproduce,  and  from  these  many  of  the  other  instincts  are 
derived. 

The  infant  smiles  in  the  fifth  week,  and  by  the  sixth  week 
eye  movements  are  complete.  By  the  ninth  week  perception 
is  being  established  and  objects  are  recognised,  and  with  the 
eleventh  week  movements  which  were  previously  aimless 
begin  to  assume  purpose,  owing  to  the  myelinisation  of  the 
pyramidal  tract.  At  this  time  surprise  and  fear  begin  to 
develop  and  there  is  an  attempt  to  imitate  sounds.  Fear 
further  develops  during  the  next  few  weeks,  and  in  the  fifth 
month  it  shows  itself  by  an  instinctive  shrinking  from  strangers. 
At  six  months  there  is  some  idea  of  space  and  distance  ; 
compare  this  with  a  chick  which  has  this  attribute  when 
hatched  from  its  shell.  Crawling  begins  about  the  tenth 
month  and  also  pleasure  is  evinced  in  making  a  noise.  The 
instinct  to  stand  appears  about  the  eleventh  month  and  this 
is  shortly  followed  by  a  desu-e  to  walk.  Instinctive  language 
of  the  *  bow-wow  '  order  appears  between  the  ninth  and  tenth 
months,    bat    voluntary   language   is   usually   not   attempted 


10  PSYCHOLOGICAL  MEDICINE 

until  about  the  sixteenth  month.  Curiosity  appears  about 
the  nineteenth  month,  and  from  the  twenty-first  to  the 
tAventy-fomih  months  cleanHness  is  developed. 

The  mstmct  of  make-believe  is  usually  present  by  the 
beginning  of  the  thnd  year.  Destructiveness  is  most  marked 
dming  the  fourth  and  fifth  years,  and  by  the  end  of  the  sixth 
year  constructiveness  should  take  its  place.  Modesty  and 
shame  appear  at  the  time  of  puberty. 

Memory. — Memory  is  so  large  a  subject  that  it  is  difficult  to 
condense  it  into  narrow  limits  ;  but  it  must  be  here  described 
in  as  few  words  as  are  compatible  with  clearness.  Kiilpe 
defines  that  which  is  understood  by  memory  in  the  following 
words  :  '  That  an  impression  which  has  been  produced  in  the 
past  by  a  particular  stimulus  does  not  disappear  outright 
with  the  cessation  of  that  stimulus,  but  is  somewhat  con- 
served, and,  under  certain  conditions,  has  the  power  of  again 
becoming  a  noticeable  part  of  conscious  contents,  without  any 
renewal  of  the  original  peripheral  stimulation.'  In  other 
words,  memory  means  the  tendency  of  the  nervous  elements 
to  fall  into  a  similar  state  of  commotion  to  that  in  which  they 
were  when  the  original  stimulus  acted  upon  them.  Cognition 
is  the  dii'ect  apprehension  of  an  object,  it  is  association  by 
similarity,  one  sees  an  object  and  at  once  cognises  what  it  is. 
Recogfiition  consists  of  three  processes :  there  is  an  object  before 
us  (Percept)  ;  and  this  percept  calls  up  by  association  other 
ideas  and  with  this  there  is  a  feeling  of  familiarity. 

Memory  differs  from  recognition  in  that  the  percept  is 
replaced  by  an  idea.  There  is  no  object  before  us,  there  is 
merely  the  mental  image  of  a  former  sensation  ;  otherwise  the 
process  is  the  same,  for  memory  stands  in  the  same  relationship 
to  recognition  as  ideation  does  to  perception.  There  are 
many  types  of  memory,  varymg  in  different  individuals. 
Memories  may  be  mainly  visual,  auditory,  tactual,  or  a  mixed 
variety  ;  other  memories  consist  largely  of  word-ideas.  Mental 
constitutions  vary,  and  to  this  fact  are  due  the  very  diverse  ways 
in  which  different  persons  remember  things.  Two  persons 
may  see  the  same  incident,  and  yet  afterwards  may  describe 
it  in  such  a  manner  that  it  is  difficult  to  conceive  that  they 
are  relating  the  same  story.  This  is  accounted  for  when  it 
is  remembered  that  the  one  may  record  what  he  saw,  and 


NORMAL  PSYCHOLOGY  11 

what  especially  fell  in  with  his  tendencies;  while  the  other, 
with  tendencies  widely  different,  reproduces  the  incident 
from  what  he  heard  or  from  some  other  standpoint.  Thus 
memory,  although  not  exact,  is  a  partial  reproduction,  the 
accuracy  of  which  largely  depends  on  the  mental  constitu- 
tion of  the  individual,  and  the  degree  of  his  attention  when 
the  impression  was  received.  Events  that  created  a  strong 
impression,  social  habits  of  everyday  recurrence,  and  recent 
events,  are  all  easily  remembered.  The  power  of  being  able 
to  forget  useless  things  is  of  great  importance  in  relieving 
the  memory.  The  marks  of  a  good  memory  are :  (1)  The 
rapidity  mth  which  the  power  of  recalling  is  acquired  ;  (2)  the 
length  of  time  during  which  the  power  of  recalling  lasts  without 
being  refreshed  ;  (3)  the  rapidity  and  accuracy  of  actual 
revival ;  and  (4)  the  power  of  forgetting  those  things  which 
are  of  no  value  or  have  ceased  to  be  of  value. 

To  cultivate  a  good  memory  it  is  necessary  to  have  (1)  a 
keen  observation  ;  (2)  a  power  of  concentrating  attention .; 
(3)  a  method  of  arranging  in  a  systematic  way  things  to  be 
remembered  ;  (4)  a  power  of  forming  association.  For  prac- 
tical clinical  purposes  memory  may  be  divided  into  two  classes 
— recent,  and  distant  or  organised  memory.  The  former  is 
the  first  to  go  in  amnesic  states,  as  it  has  a  lesser  hold  on  the 
nervous  system. 

Imagination. — Imagination  is  closely  alhed  to  memory, 
and  yet  differs  from  it  in  several  important  particulars.  A 
memory  is  more  or  less  a  recall  or  reproduction  of  a  former 
perception  or  group  of  perceptions,  whereas  imagination  is 
usually  derived  from  a  number  of  former  perceptions.  More- 
over, memory  has  with  it  a  consciousness  that  the  revival  is. 
more  or  less  familiar  and  has  been  experienced  before.  This 
is  not  the  case  with  imagination,  for  with  it  there  is  no  such 
feeling  of  familiarity.  Imagination  is  entirely  dependent  upon 
memory  for  its  existence  ;  for,  if  the  power  to  recall  past 
experiences  be  lost,  the  data  necessary  for  imagination  are 
absent. 

Movement  and  Action. — Four  forms  of  action  are  usually 
described,  viz.  reflex,  instinctive,  volitional  and  automatic 
Keflex  actions  have  no  psychical  concomitants  and  they  are  all. 
carried  out  by  the  lowest  level  of  the  nervous  system,  i.e.  fronr 


12  PSYCHOLOGICAL  MEDICINE 

the  oculo-motor  nucleus  to  the  end  of  the  spmal  cord.  Instinc- 
tive actions  differ  from  reflex  actions  in  that  they  have  psychical 
concomitants.  Professor  James  in  his  '  Prmciples  of  Psychology ' 
describes  instinct  as  follows  :  '  Instinct  is  the  faculty  of  actmg 
in  such  a  %vay  as  to  produce  certain  ends,  with  foresight  of  the 
ends  and  without  previous  education  in  the  performance.' 

Volitional  or  Voluntary  Actions  differ  from  the  actions 
already  described  in  that  they  have  conscious  antecedents  and 
conscious  concomitants.  They  are  actions  which  occur  after 
dehberation,  and  first  appear  in  mfants  about  the  age  of  seven- 
teen or  eighteen  months.  Yokmtary  action  takes  place  when 
there  is  a  conflict  of  motives  ;  and  so  long  as  this  confhct  lasts 
we  call  this  dehberation,  and  the  mdividual  remams  mactive. 
In  other  words,  in  vohtional  and  selective  actions  which  only 
take  place  dming  active  attention  there  is  an  active  weighing 
of  motives,  and  the  period  between  the  thought  of  action  and 
the  movement  is  termed  deliheratioji. 

Im'pulse  is  defined  as  an  action  which  occurs  without  delibera- 
tion ;  i.e.  it  follows  immediately  upon  the  presentation  of  a 
percept  or  idea.  It  is  also  described  as  the  simplest  form 
of  voluntary  action. 

Automatic  Actions  are  vohtional  actions  which  originally 
were  consciously  performed  but  which,  through  repetition,  have 
lost  their  psychical  concomitants.  Walking,  knitting,  etc., 
are  examples  of  this  class  of  action.  Tuke  defines  mental 
automatism  as  '  a  state  in  which  a  series  of  actions  are  performed 
^\-ithout  cerebral  action  or  conscious  wiU,  as  dm-mg  reverie 
or  in  certain  morbid  conditions.' 

Microkinesis. — Certain  spontaneous  and  micontrollable 
movements  (microkinesis)  are  seen  in  the  infant.  Warner 
infers  that  in  the  infant  brain  the  centres  act  more  or  less 
separately  and  mdependently,  and  that  it  is  only  as  evolution 
advances  and  the  centres  act  in  conjmiction  that  the  move- 
ments become  controlled.  These  fidgety  or  microkinetic  move- 
ments are  of  marked  interest,  for  in  states  of  dissolution  they 
reappear.  The  micontroUed  actions  of  dehrium  and  mania 
and  other  fidgety  movements  are  reversions  to  microldnetic 
movement  of  early  hfe. 

Judgment  and  Reasoning. — Titchener,  m  his  '  Outlines  of 
Psychology,'  defines  judgment  as  '  the  most  elementary  form 


NORMAL  PSYCHOLOGY  13 

of  intellect,'  and  reasoning  as  '  the  name  given  to  a  successive 
association  of  judgments.  ...  In  every  association  two  ideas 
are  brought  into  connection.  When  the  connection  itself  has 
become  the  object  of  attention — when,  i.e.,  we  have  found  an 
idea  of  connection,  as  distinct  from  the  ideas  which  are  con- 
nected— we  speak  of  it  as  Helation.  Eeasoning  implies  an 
idea  of  relation  ;  an  idea  which  guides  us  in  our  argument, 
as  the  idea  of  movement  guides  us  in  the  performance  of  an 
action.'  Hyslop,  in  his  book  on  '  Mental  Physiology,'  writes 
that  the  degree  of  perfection  of  judgment  depends  on — 

1.  Its  clearness,  and  this  is  interfered  with  by — 

(a)  Imperfect  observation. 

(&)  Defective  conditions  of  memory. 

(c)  Imperfect  use  and  conception  of  words. 

{d)  The  presence  of  emotional  disturbances. 

(e)  Traditions — attending  to  the  notions  of  others. 

2.  Its  accuracy,  interfered  with  by — 

(a)  Imperfect  understanding  of  propositions. 

(h)  Imperfect  observation. 

(c)  Imperfect  recall. 

{d)  Emotional  states,  strong  feelings. 

(e)  Instability  of  mental  action. 

(/)  Kapidity  of  formation  of  judgments. 

Judgment  and  reasoning,  being  so  complex,  must  very 
easUy  be  affected  by  emotions,  attention,  memory,  and  even 
perception.  It  is  not,  therefore,  surprising  that  errors  and 
disturbances  of  reasoning  should  be  common  symptoms  in  all 
forms  of  mental  disorder.  Delusions  faU  under  this  heading ; 
these  are  fully  dealt  with  in  the  next  chapter. 

Belief. — Hume  says  that  belief  is  nothing  more  than  having 
a  clear  idea  ;  when  we  have  a  clear  idea,  we  are  believing. 
Belief  is  a  subjective  variety  of  sentiment.  Disbelief  is  as 
much  a  belief  as  belief,  doubt  being  the  intermediate  state. 
Both  belief  and  doubt  are  important  and  common  symptoms 
in  mental  disorder.  Doubt  and  the  active  weighing  of  motives 
are  one  of  the  chief  causes  of  inaction  in  certain  forms  of  insanity. 
Doubt  is  a  state  of  oscillation  between  belief  and  disbelief, 


14  PSYCHOLOGICAL  MEDICINE 

and  brings  with  it  disagreeable  sensations  and  emotions  derived 
from  muscular  tension  and  restlessness.  Apart  from  definite 
mental  disease  there  is  a  large  class  of  persons  whose  usefulness 
in  life  is  constantly  being  hampered  by  doubts  as  to  whether 
they  ought  to  do  this  thing  or  that  ;  and  who,  even  when  they 
have  formed  a  decision,  are  disturbed  in  mind,  considering 
that  perhaps  they  ought  to  have  acted  otherwise. 

SeU-Consciousness. — By  '  self  '  we  mean  the  '  ego  '  composed 
■Of  a  complex  of  sensations,  perceptions,  and  affections.  In 
early  life  the  idea  of  self  is  largely  developed  from  kineesthetic 
sensations.  By  kinsesthesis  is  meant  the  sense  of  movement, 
and  the  sense  by  which  we  appreciate  direction  and  extent  of 
movement.  Kinsesthetic  sensation  is  derived  from  voluntary 
muscles  in  action,  joints,  tendons,  and  skin.  As  time  goes 
on,  the  visual  centres  assist  in  the  production  of  an  idea  of 
self,  and  also  a  certain  amount,  is  learned  about  oneself  from 
the  remarks  that  others  make.  All  through  life  sensation  is 
the  important  factor  in  our  idea  of  self ;  for  greatly  diminish 
sensation  and  you  have  to  a  large  extent,  if  not  completely, 
taken  away  the  consciousness  of  self.  There  is  no  doubt  that 
this  fact  is  not  as  fully  realised  as  it  ought  to  be,  and  yet  it  is 
the  basis  of  nmnj  delusions  in  the  insane.  Patients  who 
have  the  belief  that  they  are  dead  will  usually  be  found  to 
have  an  almost  complete  anaesthesia  of  the  body.  One  patient, 
whose  sensation  is  markedly  affected,  believes  that  he  can  fly, 
while  another  will  state  that  he  '  weighs  tons.'  Self-con- 
sciousness is  defined  by  Titchener  as  '  a  consciousness  in  which 
the  concept  or  idea  of  self,  or  some  phase  or  part  of  it,  is 
present  in  the  state  of  attention,  and  thus  serves  as  a  centre 
of  association  for  other  ideas.'  A  person  who  is  self-conscious 
is  an  individual  who  is  eminently  introspective. 

Subject-Consciousness  and  Object-Consciousness. — Subject - 
.Consciousness  and  Object-Consciousness  are  terms  frequently 
used  in  text-books  on  mental  disorder.  They  are  words 
which  were  introduced  by  Bevan  Lewis,  and  are  very  useful  in 
expressing  '  self '  and  its  relationship  to  its  surroundings. 
Subject-consciousness  is  what  I  know,  what  I  feel ;  while 
.object-consciousness  is  the  knowledge  of  things  of  the  external 
world.  The  '  ego  '  is  therefore  conjoined  subject-  and  object- 
consciousness.     Bevan  Levis,  in  his  excellent  work  on  Mental 


NORMAL  PSYCHOLOGY  15 

Disease,  lays  much  stress  on  the  rise  of  subject-consciousness 
and  fall  of  object-consciousness  in  mania  and  melancholia, 
and  explains  many  of  the  mental  symptoms  from  this  stand- 
pomt.  No  doubt  he  is  perfectly  correct  in  his  deductions, 
but  it  is  probably  true  that  in  all  disease,  physical  as  well  as 
mental,  there  is  a  rise  of  subject-consciousness  and  a  corre- 
sponding fall  in  object-consciousness.  Even  the  patient  with 
a  severe  toothache  takes  little  interest  in  his  environment, 
but  his  subject-consciousness  is  decidedly  raised.  Farther 
reference  will  be  made  to  this  subject  when  dealing  with 
'  General  Symptomatology,'  for  it  certainly  explains  and 
largely  accomits  for  several  important  symptoms  usually 
present  in  such  disorders  as  melancholia. 

Reaction  Times. — Until  comparatively  recent  times  psycho- 
logists relied  chiefly  upon  introspection  for  the  study  of  mental 
processes.  The  tendency  of  later  years  has  been  more  in  the 
direction  of  experimental  methods.  The  exponents  of  purely 
introspective  psychology  object  to  experimental  study  on  the 
ground  that,  by  placing  an  individual  under  standard  con- 
ditions, the  ordinary  mental  state  of  that  individual  is  altered. 
This  is  probably  true,  and  must  be  always  borne  in  mind 
when  doing  experimental  work.  On  the  other  hand,  in  the 
older  psychology,  far  too  much  was  left  to  the  personal  equa- 
tion of  the  observer  ;  and  this,  no  doubt,  is  the  reason  why  the 
older  psychologists  differ  so  much  in  their  results.  No  control 
could  be  kept  on  their  observations,  and  each  recorded  what  he 
considered  to  be  the  workings  of  his  own  mind.  Experiment 
cannot  take  the  place  of  introspection,  but  it  can  usefully  supple- 
ment it.  By  experiment  we  mean  the  placing  of  an  individual 
under  standard  conditions.  The  same  experiments  can  be 
repeated,  and  control  experiments  made.  The  most  common 
form  of  experiment  is  reaction-time  observations.  These  re- 
action-time experiments  may  be  either  (1)  simple,  or  (2) 
compound.  The  methods  of  procedure  are  these  :  The  in- 
dividual who  is  being  tested,  for  the  purpose  of  convenience 
here  called  the  reactor,  is  told  to  make  a  certain  pre-arranged 
movement  on  receiving  a  certain  sensory  stimulus,  given  and 
controlled  by  the  experimenter.  The  time  elapsing  between 
the  application  of  the  sensory  stimulus  and  the  execution  of  the., 
movement  is  accurately  measured. 


16  PSYCHOLOGICAL  MEDICINE 

A  simple  reaction-time  experiment  may  be  of  two  kinds  : 
(a)  sensory,  and  (&)  motor.  In  the  case  of  the  former,  the 
reactor  directs  his  attention  to  the  sensory  stimulus,  whether 
it  be  a  Mght  or  sound  of  a  bell,  which  he  will  receive,  and 
not  towards  the  movement  he  has  to  make,  commonly  the 
pressm'e  on  the  bottom  of  an  electric  apparatus. 

In  the  motor  reaction,  the  reactor  attends  to  and  thinks  of 
the  movement  he  has  to  make  when  he  receives  the  stimulus. 
Thus  it  will  be  seen  that  the  motor  reaction  more  nearly 
resembles  a  reflex  action,  and  is  therefore  a  more  rapid  re- 
action than  the  sensory  one.  With  these  reactions  as  a  base, 
it  is  possible  to  add  to  their  complexity  in  a  number  of  ways, 
and  such  complex  reactions  are  known  as  compound  reactions. 
They  can  be  made  very  compHcated,  in  which  case  the  dura- 
tion of  the  reaction  will  be  correspondingly  longer.  The 
reactor  may  have  several  known  or  unknown  stimuli  to  which 
he  is  to  react,  and  be  told  only  to  react  when  he  has  fully 
cognised  the  stimulus.  For  instance,  in  a  choice  reaction, 
he  may  have  choice  of  signal  and  choice  of  reaction,  as  when 
letters  are  spoken  to  him  or  exhibited  on  a  photographic 
shutter,  and  he  is  told  to  react  with  his  right  hand  for  all 
vowels  and  with  his  left  for  consonants.  Munsterberg  has 
done  much  work  on  association  reactions.  His  method  was 
to  call  out  a  word  aloud  to  the  subject,  who  then  had  to  give 
his  first  clear  idea  associated  with  the  word.  He  found  that 
persons  could  be  fairly  classified  into  three  types  :  (1)  those 
who  associated  heneatli — e.g.  '  hand  '  called  out  and  '  finger  ' 
given  by  the  subject ;  (2)  those  who  answered  by  giving  a 
ivhole  of  which  the  word  was  part — e.g.  '  hand  '  called  out 
and  '  arm  '  given  by  the  subject ;  and  (3)  those  who  gave 
an  analogue — e.g.  '  hand  '  called  out  and  '  foot  '  given  by 
subject.  These  Munsterberg  considered  corresponded  to  types 
of  intellect ;  Class  No.  1  tending  to  deal  with  detail,  Class 
No.  2  tending  to  generalise,  and  Class  No.  3  tending  to  be  witty. 
Experimental  psychology  may  prove  to  be  of  great  use  in  the 
training  of  children  ;  it  may  be  possible  in  this  way  to  discover 
what  faculties  are  most  acute  in  each  child.  So  also  in  mental 
disease  diagnosis ;  reaction  times  are  longer  in  the  insane,  and 
they  give  more  premature  reaction ;  i.e.  they  react  too  soon,  be- 
fore the  sign  or  stinmlus  has  been  given.     Premature  reactions 


NORMAL  PSYCHOLOGY  17 

are  also  common  in  fatigue  states.  In  experimental  work 
among  the  insane  it  is  of  interest  to  observe  the  influence 
of  distraction,  the  power  of  estimating  time,  etc.  Memory, 
too,  may  be  tested  by  such  methods  as  those  employed  by 
Ebbinghouse. 

Dream  States. — Dream  states  must  ever  be  of  intense 
interest  to  the  physician  whose  work  is  devoted  to  the  study 
of  mental  disorder.  Some  forms  of  insanity  seem  to  be 
closely  allied  to  a  condition  of  dream-consciousness,  and  the 
dreams  of  the  sane  often  show  a  marked  resemblance  to  the 
hallucinations  of  the  insane.  We  probably  dream,  if  the  word 
can  be  used  in  this  sense,  in  all  stages  of  sleep  ;  but  it  is  only 
during  light  sleep  that  we  can  remember  the  fact  that  we  have 
been  dreaming.  Dreams  may  be  set  up  by  any  stimuli ;  some 
authorities  consider  that  visual  dreams  are  not  uncommonly 
started  by  changes  in  the  circulation  of  the  retina. 

Aristotle  pointed  out  that  as  in  sleep  the  senses  are  no 
longer  occupied  with  external  objects,  internal  operations  are 
therefore  more  easily  perceived.  During  dreams,  inattention  is 
extreme  ;  every  stimulus  has  an  equal  chance,  free  from  the 
influence  of  reinforcement  or  the  control  of  inhibition.  Prob- 
ably this  extreme  inattention  largely  accounts  for  the  grotesque 
arrangements  of  ideas  during  sleep.  To  a  certain  extent  the 
laws  of  habit  and  association  regulate  ideas  in  dreams  ;  but 
the  association  is  constantly  being  interrupted  by  a  fresh 
stimulus,  starting  fresh  ideas.  The  sensory  centres  are  active 
during  sleep,  so  that  things  are  commonly  seen  and  heard. 
Ideas  may  be  very  clear  and  vivid  in  dreams,  a  fact  which 
has  been  advanced  as  an  argument  in  explanation  of  the 
ready  manner  in  which  they  are  accepted  as  realities.  Periods 
of  time  are  greatly  abridged,  and  in  the  space  of  a  few  moments 
a  dreamer  will  pass  through  what  seem  to  be  the  events  of 
hours.  The  dreamer  usually  is  indifferent  to  the  presence 
of  others  in  the  drama  of  his  dream,  and  he  will  do  all  kinds 
of  ridiculous  things  without  a  thought  of  the  criticism  of 
those  who  are  witnesses  of  his  folly.  If  reasoning  and  judg- 
ment are  weak,  as  in  dreams  they  clearly  are,  conscience 
may  be  as  active  as  in  the  daytime.  We  again  refer  to  dreams 
when  describing  the  method  of  investigation  known  as  psycho- 
analysis. 

2 


18  PSYCHOLOGICAL  MEDICINE 

Tui'mng  fi'om  the  study  of  dreams  to  insanity,  the  points 
of  similarity  are  apparent.  A  brief  recapitulation  of  the 
chief  characteristics  of  the  state  of  the  dreamer,  and  a  com- 
parison of  these  ^vith  the  state  of  insanity,  wUl  demonstrate 
the  justice  of  this  observation.  Attention  fails  in  both  ;  and  in 
some  forms  of  mental  disorder  ideas  are  fantastic  in  arrange- 
ment, as  in  the  case  of  dreams,  the  laws  of  association  and 
habit  only  having  partial  control.  The  ideas  in  the  insane 
seem  to  be  equallj^  vivid  and  impressive  Avith  those  of  the 
dreamer  and  to  carrj-  with  them  the  force  of  conviction. 
Time  is  not  uncommonly  abridged  in  insanity  as  in  dreams, 
and  days  seem  to  be  years.  The  maniac  and  many  other 
insane  persons  are,  hke  the  dreamer,  entirely  indifferent  to 
the  presence  of  others,  subject-consciousness  being  in  the 
ascendant  and  object-consciousness  correspondingly  lessened. 
The  powers  of  reasoning  and  judgment  are  in  abeyance, 
whereas  conscience  may  be  stronger  than  ever.  Aristotle 
might  have  explained  certain  mental  states  as  he  explained 
dream-consciousness  ;  for  there  can  be  no  doubt  that  many  of 
the  insane  have  their  attention  constantly  directed  to  the 
workings  of  their  internal  organs,  but  at  the  same  time  their 
special  senses  are  found  to  be  less  occupied  with  their  sur- 
roundings and  the  affans  of  others. 

The  psychology  which  has  been  described  in  this  chapter 
is  of  a  very  rudimentary  nature.  The  end  in  view  has  been 
merely  to  show  the  student  some  of  the  workings  of  the  human 
mind,  in  order  that  he  may  more  readily  recognise  mental 
disease  in  its  earliest  forms.  But  this  is  not  all ;  some  know- 
ledge of  normal  psychology  will  make  him  a  more  successful 
physician,  for  he  will  no  longer  look  upon  mental  disorder  as 
a  hopelessly  obscm-e  disease  in  which  the  symptoms  are 
outside  the  limits  of  human  understanding;. 


19 


CHAPTEE  II 

•WHAT   IS   INSANITY  ? 

Insanity,  Like  sanity,  is  indefinable.  Insanity  connotes  the 
absence,  whether  by  non-acquisition  or  loss,  of  some  of  the 
elements  which  go  to  make  up  what  we  miderstand  by  sanity. 
Sanity  is,  however,  not  to  be  ascertained  by  any  definite 
.standard.  Sanity  and  insanity  are  both  relative  terms. 
Insanity  is  a  negation  of  the  state  of  sanity,  while  sanity  is 
measured  by  an  approximation  to  the  normal,  as  kno\\Ti  in 
the  experience  of  the  human  race.  Sanity,  as  appUed  to  cer- 
tain persons,  does  not  connote  mental  perfection,  nor  insanity 
something  less  than  mental  perfection.  It  is  impossible  to 
find  a  person  with  so  healthy  and  perfect  a  body  that  some 
shght  deformity  or  degeneracy  cannot  be  observed.  So,  it  is 
impossible  to  find  a  perfect  mmd.  But  it  is  not  by  perfec- 
tion that  sanity  is  measured,  and  insanity  is  not  determuied 
b}^  relation  to  perfection,  but  by  relation  to  sanity.  It  is  by 
no  means  uncommon  in  cases  involving  an  issue  of  sanity  to 
hear  counsel  ask  a  witness  to  define  what  he  means  by  insanity  ; 
but  woe  betide  that  witness  if  he  tries  to  give  an  answer  in 
the  terms  of  the  question,  that  is  to  say,  in  the  form  of  a 
definition.  There  is  no  definition  possible  which  would  not 
include  in  its  Hmits  a  large  number  of  persons  accredited  to 
be  sane,  and  fail  to  include  a  goodly  number  of  those  whom 
it  was  intended  to  comprehena.  Premising,  therefore,  that  it 
is  impossible  to  define  insanity,  it  is  nevertheless  necessary, 
for  educational  purposes,  to  be  dogmatic  even  at  the  risk  of 
being  wrong.  The  student  must  have  something  definite, 
something  tangible,  around  which  he  may  centre  his  ideas. 
A  working  rule  must  be  found,  and  for  practical  pm'poses  the 
following  is  probably  the  best  that  can  be  given  :  A  person 
may  be  considered  of  unsound  mind  if  from  some  mental  cause 


20  PSYCHOLOGICAL  MEDICINE 

(1)  he  is  miable  to  look  after  himself  and  his  affairs,  (2)  he 
is  dangerous  to  himself  or  others,  or  (3)  he  interferes  with 
society.  In  considermg  mental  disorder  three  questions  most 
be  borne  in  mind  and  separately  considered.  In  the  first 
place,  there  is  the  '  self,'  which  is  composed  of  the  sum-total 
of  subjective  sensations,  perceptions,  feehngs,  and  ideas  at 
any  given  moment.  We  depend  largely  upon  kineesthetic 
(kinsesthesis  =  sense  of  movement)  sensation  for  our  know- 
ledge of  self,  for  by  means  of  it  we  know  of  our  relationship 
to  our  environment.  Now,  kinsesthetic  sensation  is  derived 
from  (1)  the  muscles  in  action,  (2)  joints  moved,  (3)  tendons, 
fasciae,  and  skin.  Accordmg  to  Bastian,  the  so-called  motor 
area  is  the  centre  of  kinsesthesis  in  the  brain.  Every  time 
a  movement  is  made  we  receive  a  group  of  sensorial  impres- 
sions occasioned  by  and  pecuhar  to  that  movement.  Diminish 
sensation,  and  you  have,  to  a  certain  extent,  taken  away  the 
consciousness  of  self.  That  disordered  sensation  has  a  marked 
effect  upon  the  individual  ideas  of  self  is  clearly  seen  in  several 
forms  of  mental  disorder,  where  altered  sensation  is  a  promi- 
nent symptom.  A  patient  in  Bethlem  Hospital  had  the  beUef 
that  she  was  dead,  and  upon  examining  her  sensations  it  was 
found  that  she  had  a  general  and  well-marked  anaesthesia. 

The  second  factor  we  must  consider  in  dealing  with  mental 
disorder  is  enzironmeni.  There  are  different  grades  of  society, 
and  the  customs  and  habits  of  those  grades  vary.  Omitting 
for  the  present  degeneracy,  as  it  is  found  in  all  divisions  of 
society,  we  find  that  the  lower  we  go  in  the  social  scale  the 
less  we  expect  to  see  such  attributes  as  moraUty  and  control 
fully  developed.  In  the  lower  grades  of  society  education  is  of 
a  more  rudimentary  nature,  and  therefore  less  is  expected  of  a 
man  who  belongs  to  this  class.  Likewise,  in  dealing  with  crime 
and  insanity,  the  question  of  environment  must  always  be  con- 
sidered ;  but  this  subject  is  dealt  with  in  a  subsequent  chapter. 

The  third  factor  is,  m  many  ways,  the  most  important  of 
all,  and  that  is  the  adjustment  of  the  first  and  second  factors, 
which  is  the  *  adjustment  of  self  to  surroundings.'  Mercier, 
in  his  excellent  work  entitled  '  Sanity  and  Insanity,'  has  defined 
conduct  as  '  the  adjustment  of  self  to  surroundings,'  and  no 
better  definition  can  be  conceived,  as  this  adjustment  seems  to 
be  the  very  essence  of  conduct.    In  msanity  we  have  to  deal 


WHAT  IS  INSANITY  ?  21 

with  failure  of  adjustment  of  self  to  environment.  Now  this 
failm'e  may  show  itself  in  many  ways.  The  sufferer  may 
neglect  the  most  rudimentary  and  necessary  requirements  of 
life.  Food  may  neither  be  sought  nor  eaten,  even  when  it  is 
placed  within  reach.  The  ordinary  laws  of  self-conservation 
may  be  neglected :  he  may  fail  to  protect  himself  from 
perils  which  endanger  his  very  life.  The  rules  of  personal 
cleanliness  may  be  unobserved.  The  ability  to  earn  a  living 
may  be  absent.  Acts  of  violence  against  themselves  or  others 
may  be  a  prominent  symptom  in  the  conduct  of  some  persons. 
We  are  born  into  a  community,  and  have  to  adapt  ourselves 
to  a  social  and  moral  code  of  laws.  This  code  of  laws  deter- 
mines what  we  may  do  and  what  we  may  not  do  ;  it  lays 
down  rules  as  to  personal  property,  and  creates  the  distinction 
between  meum  and  iuum.  Some  persons  fail  to  adjust  them- 
selves to  these  laws,  and  their  conduct  is  disordered  in  that 
they  fail  to  distinguish  between  their  property  and  that  of 
others.  Others  neglect  to  conform  to  the  laws  of  decency  and 
propriety  as  dictated  by  society.  These  are  a  few  examples 
of  the  ways  in  which  disordered  conduct  may  show  itself. 
Although  a  judgment  of  a  person's  sanity  may  be  formed  either 
by  noting  his  conversation  or  observing  his  conduct,  it  is 
largely  the  state  of  the  latter  that  decides  whether  he  is  to 
retain  his  liberty  or  not.  Society  rules  that  the  liberty  of  the 
subject  is  only  possible  so  long  as  that  liberty  is  not  used  to 
interfere  with  the  liberty  of  others.  From  this  it  is  clear  that 
it  is  society  which  demands  that  such  persons  who  fail  to 
adjust  themselves  to  their  surroundings,  and  whose  conduct  is 
dangerous  either  to  themselves  or  others,  should  be  placed 
under  care.  Some  persons  are  much  more  insane  in  their 
conversation  than  they  are  in  theii'  conduct,  while  in  others 
the  mental  aberration  is  more  noticeable  in  theu'  conduct 
than  in  their  conversation.  When  a  man's  conversation  is 
wild  and  rambling,  or  replete  with  strange  fancies  and  delu- 
sions, there  is  no  difficulty  even  for  the  lay  mind  to  diagnose 
that  he  is  suffering  from  some  mental  disorder.  But  the 
difficulty  to  the  lay  mind  is  much  greater  when  it  is  the  con- 
duct that  is  chiefly  at  fault,  especially  when  the  vagaries  of 
conduct  are  slight  ;  and  yet  the  patient  with  disordered 
conduct  is  usually  the  more  dangerous  person. 


22  PSYCHOLOGICAL  MEDICINE 

The  insane  usually  keep  to  themselves  ;  they  feel  that 
they  are  not  in  touch  with  the  thoughts  and  feelings  of  others, 
either  because  they  believe  that  they  are  of  such  a  nature 
as  renders  them  unfit  to  associate  with  the  world,  or  that 
mankind,  by  hint  or  persecution,  has  clearly  shown  them 
that  they  are  not  wanted.  The  healthy-minded  man  is 
gregarious  :  the  insane  is  solitary.  This  is  one  of  the  symp- 
toms by  which  the  physician  knows  when  a  patient  with 
mental  disorder  has  returned  to  health.  During  his  illness 
he  keeps  to  himself  and  is  self-absorbed  ;  but  when  he  recovers 
he  associates  with  others.  There  are  exceptions  to  this 
rule,  for  some  persons  during  their  insanity  devote  them- 
selves to  an  almost  extravagant  extent  to  helping  others  ; 
but  nevertheless  their  mental  aberration  is  usually  clearly 
indicated  in  other  ways,  and  is  even  evidenced  by  the  manner 
in  which  they  render  theii-  assistance.  Another  character- 
istic of  the  disordered  mind  is  the  defect  of  judgment  usually 
evinced.  Some  of  the  insane  are  ready  to  believe  any  state- 
ment, however  extravagant  or  improbable  ;  others  only  believe 
their  own  opinion  to  be  correct,  notwithstanding  that  it  is 
unsupported  by  evidence  and  contrary  to  the  ideas  of  every- 
body else.  The  question  of  delusions  has  been  fully  gone  into 
elsewhere,  and  therefore  it  is  unnecessary  to  detain  the  reader 
fm'ther  than  to  emphasise  the  fact  that  insanity  can  exist 
without  delusions,  and  delusions  may  occur  in  persons  who 
are  not  insane.  Some  people  would  have  us  believe  that 
false  beliefs  are  the  very  essence  of  insanity,  and,  indeed, 
would  almost  hesitate  to  certify  a  man  as  a  person  of  un- 
sound mind  if  no  delusions  could  be  discovered.  A  truly 
dangerous  doctrine,  for  some  of  the  most  homicidal  and  im- 
pulsive patients  have  no  delusions.  When  present,  delusions 
may  be  most  valuable  data,  in  conjunction  with  other  evidence, 
in  conclusively  proving  the  trae  mental  state  of  a  patient. 
•For  further  information  on  this  topic  the  reader  must  refer 
to  the  passage  on  delusions  which  Avill  be  found  in  the 
chapter  on  General  Symptomatology. 

Again,  insanity  is  not  proved  by  the  presence  of  hallucina- 
tions or  other  sensory  disorders,  for  they,  like  delusions,  may 
exist  apart  from  certifiable  mental  disorder.  Clearly  they  indi- 
cate disturbances  of  nervous  functions,  but  such  disturbances 


WHAT  IS  INSANITY  ?  23 

may  take  place  within  the  realm  of  sanity.  Nevertheless, 
in  any  given  case,  hallucinations  may  be  one  of  the  factors 
which  go  to  prove  the  insanity  of  the  patient,  and  may  even  be 
the  symptom  which  determines  the  line  of  treatment.  Insanity 
is  not  evidenced  by  one  symptom,  but  a  group  of  symptoms. 
A  man  may  be  depressed,  a  man  may  have  a  delusion,  a 
man  may  have  an  hallucination,  a  man  may  be  emaciated 
and  in  bad  physical  health,  and  yet  not  be  insane  ;  but  if  he 
has  all  these  he  is  almost  certainly  insane.  Disorders  of 
the  normal  feehngs  and  emotions  frequently  connote  insanity. 
A  man  may  hear  of  the  death  of  a  near  and  loved  relative 
without  evincing  the  slightest  concern.  Now,  if  such  a 
man  has  been  in  the  past  one  who  has  not  only  keenly  felt 
domestic  losses,  but  has  exhibited  emotion,  the  present  apathy 
and  apparent  callous  behaviour  are  probably  indicative 
of  severe  mental  disorder.  In  health  we  react  to  pleasure 
and  pain,  and  those  about  us  observe  the  effect  of  those 
sensations  upon  us.  But  in  insanity  this  is  altered,  and 
unusual  reactions  follow  these  stimuli.  Again,  the  healthy 
mind  sees  good  in  all  men  ;  to  hate  is  almost  alien  to  it,  and 
even  dislike  is  kept  within  narrow  bounds.  But  the  converse 
is  equally  true  :  in  sanity  love  is  bestowed  only  on  a  chosen 
few,  who,  by  ties  of  relationship  or  exceptional  friendship,  are 
its  proper  recipients.  The  insane  are  often  bound  by  no 
such  limitations,  and  are  ready  to  thrust  their  affections  upon 
any  who  will  receive  them.  The  girl  who  in  health  is  reserved 
and  maidenly  in  her  attitude,  frequently  becomes  forward 
and  immodest  when  insane.  The  study  of  the  moral  sense, 
even  in  the  apparently  healthy-minded,  is  most  complex. 
We  see  men  who  are  possessed  of  exceptional  intellectual 
powers,  men  who  have  within  them  the  fire  of  genius,  men 
who  are  endowed  with  brilliant  talents,  but  whose  moral 
sense  is  most  rudimentary.  Are  their  shortcomings  to  be 
considered  under  the  head  of  vice  or  disease  ?  Such  men 
may  be  capable  of  writing  prose  or  verse,  every  line  of  which 
glows  with  lofty  ideals  or  subhme  thought,  and  then,  laying 
aside  the  pen,  they  prepare  to  do  some  action  which,  maybe, 
entails  doing  grievous  wrong  to  some  fellow-creature. 

If  a  number  of  the  mental  attributes  of  such  a  man  were 
as  shallow  as  his  moral  sense,  he  would  have  to  be  classed 


24  PSYCHOLOGICAL  MEDICINE 

as  insane  ;  but  %Yhen  the  degradation  is  partial,  it  is  usually- 
spoken  of  as  vice.  In  determining  a  question  of  insanity 
where  the  moral  or  some  other  sense  is  involved,  the  present 
conduct  must  be  compared  with  the  past.  Slow  deterioration 
extending  over  years  is  more  difficult  to  treat  as  insanity  than 
some  sudden  change.  All  change  of  habit  connotes  an  altered 
mental  state,  and  the  nature  of  the  variation,  as  shown  by 
thought  and  action,  marks  whether  it  is  the  result  of  higher 
evolution  or  dissolution.  In  this  connection  the  words  of 
Maudsley  ^  may  be  usefully  quoted  as  well  summarising  the 
position  of  the  insane  unit  in  relation  to  the  social  whole  : 
*  By  insanity  of  mind  is  meant  such  derangement  of  the  lead- 
ing functions  of  thought,  feeling,  and  will,  together  or  separately, 
as  disables  the  person  from  thinking  the  thoughts,  feeling 
the  feehngs,  and  doing  the  duties  of  the  social  body  in,  for, 
and  by  which  he  lives.  .  .  .  Insanity  means  essentially,  then, 
such  a  want  of  harmony  between  the  individual  and  his  social 
medium,  by  reason  of  some  defect  or  fault  of  mind  in  him, 
as  prevents  him  from  hving  and  working  among  his  kind  in  the 
social  organisation.  Completely  out  of  tune  there,  he  is  a 
social  discord  of  which  nothing  can  be  made.'  Mental  dis- 
order may  be  due  to  a  failure  of  evolution  ;  such  an  organism 
is  not  endowed  with  those  intellectual  attributes  with  which 
nature  usually  equips  a  man.  Eeason  and  judgment,  purpose 
and  control,  have  been  denied  him.  Small  wonder  that  as  he 
grows  up  he  finds  himself  out  of  touch  with  his  fellow-men, 
and  unable  to  compete  on  an  equality  with  them  in  the  battle 
of  life.  He  drifts,  swayed  by  his  lower  instincts,  which  lack 
the  control  of  higher  attributes.  On  the  other  side  we  see  the 
effects  of  dissolution  ;  here  the  once  intellectual  man  loses 
the  attributes  he  originally  possessed,  or,  if  not  losing  the 
attributes,  loses  the  proportion  and  correspondence  between 
them  which  are  necessary  to  an  even  and  balanced  mind. 
Disordered  sensation  or  strong  emotion  may  usurp  the  whole 
attention,  to  the  detriment  of  other  faculties.  Sensory  illusions 
may  deceive  the  man  and  bias  his  conduct,  or  profound 
depression  may  paralyse  both  thought  and  movement.  But, 
let  it  be  remembered,  insanity  is  not  revealed  by  one  symptom : 
the  change  can  be  seen  in  everything,  physical  or  mental. 
^  Patholofjy  of  Mind,  ch.  i. 


WHAT  IS  INSANITY  ?  25 

Decay  is  not  limited  to  one  organ,  but  affects  the  body  as  a 
whole.  The  dissolution  may  be  uneven,  and  the  degeneration 
in  one  part  may  far  exceed  that  of  another  ;  nevertheless, 
the  whole  is  affected.  In  determining  insanity  the  evidence 
to  establish  it  cannot  be  derived  from  one  symptom.  The 
symptoms  present  may  be  regarded  much  in  the  same  way  as 
pieces  of  circumstantial  evidence  are  during  a  trial.  Each 
individual  piece  denotes  nothing,  but  the  chain  formed  by 
welding  the  separate  pieces  together  may  be  so  strong  as  to 
compel  one  conclusion.  So  with  the  symptoms  of  insanity. 
Each  of  them  present  alone  might  be  consistent  with  sanity, 
but  taken  together  they  may  form  so  strong  a  body  of  evidence 
as  to  forcefthe  inference  of  insanity. 


26  PSYCHOLOGICAL  MEDICINE 


CHAPTEE  III 

CAUSATION    OF    INSANITY 

Much  has  been  written  and  much  will  continue  to  be  written 
upon  this  subject,  a  subject  so  full  of  interest  and  importance 
to  the  human  race  ;  but  before  entering  upon  it  one  word  of 
warning  may  usefully  be  given.  It  is  not  always  safe  to 
accept  either  the  apparent  cause  of  a  mental  breakdown  or 
the  cause  to  which  the  friends  of  the  patient  may  attribute 
it.  Causes  and  early  symptoms  of  disorders  are  constantly 
being  confused,  and,  although  there  may  be  no  intention  to 
mislead,  if  the  physician  is  careless  or  too  readily  accepts  data, 
his  deduction  may  be  entirely  erroneous.  Take,  for  instance, 
the  question  of  alcohol ;  this  may  be  given  as  the  cause  of 
the  mental  disorder,  and  yet  inquiry  may  elicit  that  the  intem- 
perance was  of  recent  development,  being  in  fact  the  first  sign 
that  the  patient  was  losing  control.  In  all  matters  appertaining 
to  our  daily  life,  each  of  us  is  constantly  seeking  for  explana- 
tions of  this  or  that  phenomenon,  and  may  determine  upon  a 
solution  which  is,  in  fact,  entirely  erroneous.  A  person  who 
develops  an  ordinary  cold  in  the  head  is  not  satisfied  until 
he  finds  out  how  he  got  it,  and  having  allocated  it  to  coming 
out  of  a  heated  theatre,  or  sitting  by  an  open  window,  he  is 
perfectly  satisfied  with  his  conclusions,  however  mistaken 
they  may  be.  In  determining  causation,  the  physician 
cannot  be  too  careful  in  his  inquiry  or  too  guarded  in  his 
conclusions.  Many  classifications  of  causation  of  mental 
disorder  have  been  from  time  to  time  drawn  up,  but  all  of 
them  are  more  or  less  unsatisfactory.  The  system  of  dividing 
the  causes  up  into  predisposing  and  exciting  is  perhaps  as 
confusing  as  any,  for  factors  such  as  syphilis  and  alcohol 
may  be  either  predisposing,  or  exciting,  or  both.  The  student 
will  be  wiser  to  take  a  much  wider  scheme  to  liegin  with, 


CAUSATION  OF  INSANITY  27 

and  then,  if  he  so  wishes,  subdivide  afterwards.  The  system 
used  by  Mercier,  whereby  the  main  causes  are  divided  under 
two  heads,  Heredity  and  Stress,  is  one  which,  at  any  rate, 
commends  itself  by  its  simphcity.  By  inheritance  it  is  meant 
that  the  child  tends  to  inherit  every  attribute  of  the  parent. 
Our  nervous  system,  like  any  other  system  of  the  body,  bears 
in  all  probability  the  stamp  of  our  ancestors  upon  it.  If 
our  parents  or  grandparents  have  had  an  unstable  nervous 
system,  the  tendency  is  that  we  shall  be  unstable  in  the  same 
direction.  We  would  especially  emphasise  the  word  tendency, 
for,  after  all,  it  is  nothing  more.  Because  our  ancestors  were 
of  unsound  mind,  it  is  no  reason  why  we  should  become  insane  ; 
all  we  inherit  is  a  tendency,  not  a  certainty,  to  be  unstable, 
so  far  as  our  own  nervous  system  is  concerned.  Now  this  is 
very  important  to  fully  realise  and  remember,  for  so  many 
persons  spend  their  life  worrying  about  their  future  because 
their  inheritance  is  not  sound.  After  all,  it  is  a  great  advan- 
tage to  know  the  weak  point  in  one's  armour,  so  that  that 
part  may  be  guarded  against  undue  stress.  Moreover,  it  is 
this  knowledge  of  tendencies  that  is  practically  the  keynote  of 
preventive  treatment,  and  the  guide  by  which  life  should  be 
regulated. 

Degeneracy  in  the  parent  may  be  evidenced  by  insanity 
of  all  kinds,  epilepsy,  alcoholism,  moral  perversion,  and  the 
like — and  the  presence  of  any  such  element  of  degeneracy  in 
the  parent  is  apt  to  engender  in  the  offspring  similar  defects-, 
or  a  state  of  general  instability.  On  the  other  hand,  the 
children  of  such  a  parent  may  be  apparently  healthy,  but  in 
turn  their  offspring  may  exhibit  symptoms  of  mental  disorder. 
In  this  case  the  elements  of  insanity  are  apparently  latent  in 
the  second  generation,  but  in  the  third  there  is  a  reversion  to 
the  original  condition.  This  reversion  is  known  as  Atavism. 
Further,  it  has  been  noted  that  where  we  find  insanity  appear- 
ing in  several  generations,  the  tendency  is  for  it  to  appear 
earlier  in  each  successive  generation  ;  this  is  probably  only 
true  in  families  where  the  taint  is  exceptionally  strong.  It 
must  also  be  remembered  that  the  danger  of  insanity  to  the 
offspring  is  greater  as  the  begetting  of  the  child  is  nearer  to 
the  insanity  in  the  parent.  On  the  other  hand,  from  time  to 
time  one  finds  an  insane  family  whose  parents  are  not  insane, 


28  PSYCHOLOGICAL  MEBICTNE 

and  in  whose  relatives  no  marked  insanity  can  be  ascertained. 
Before  leaving  this  question  of  Inheritance,  reference  may  be 
made  to  one  other  law  which  Mercier  calls  the  '  Law  of  San- 
guinity,'  and  which  he  explains  in  the  following  way  :  '  There 
is  a  certain  degree  of  dissimilarity  (sanguinity)  between  parents, 
which  is  most  favom-able  for  the  production  of  well-organised 
offspring  ;  and  parents  who  are  more  similar  (consanguinity) 
or  more  dissimilar  (exsanguinity)  t\^11  have  offspring  (if 
any)  whose  organisation  will  be  inferior  in  proportion  to 
the  distance  of  the  parents  from  the  most  favourable  point.' 
In  other  words,  this  means  that  the  more  dissimilar,  up  to 
a  certain  point,  parents  are,  the  stronger  and  better  the  off- 
spring, but  that  individuals  whose  constitutions  and  tem- 
peraments are  ahke  will  either  have  no  children  or  degenerate 
children.  Now,  this  law  largely  decides  the  question  of  the 
marriage  of  first  cousins.  If  the  parties  who  are  contem- 
plating marriage  are  of  blood-relationship,  and  if  in  both 
families  the  stock  is  markedly  degenerate,  and  if  this 
degeneracy  is  exhibited  by  instability  or  neurotic  symptoms 
in  the  individuals  in  question,  then  it  is  extremely  probable 
that  the  offspring  of  such  a  marriage  would  be  degenerate. 
Conversely,  if  there  is  no  such  similarity  of  constitution, 
notwithstanding  the  blood-relationship,  the  offspring  would 
in  all  probability  be  healthy. 

We  will  now  pass  on  to  the  stresses,  which  may  be  of  two 
kinds  :  (1)  Direct,  (2)  Indirect.  The  direct  stresses  include 
factors  such  as  Brain  Tumours,  Cerebral  Haemorrhage,  Injuries 
to  Cranium  or  Brain,  and  Inflammation  of  Meninges  or  Brain 
itself.  Among  the  direct  stresses  we  must  also  include  poisons 
circulating  in  the  blood  ;  these  may  be  autotoxins  or  toxins 
derived  from  external  agents.  Every  year  brings  more  and 
more  convincing  evidence  of  the  importance  of  recognising 
that  autotoxins  derived  from  the  alimentary  tract  play  no 
small  role  in  the  production  of  insanity.  Blood  changes,  in- 
cluding poisons  circulating  in  the  blood,  have  for  some  time 
past  been  placed  in  a  prominent  position  among  the  various 
factors  to  be  considered  when  studying  physical  disease.  The 
case  is  no  different  in  insanity,  and  it  may  fairly  be  said  that 
the  advantages  to  be  gained  by  a  careful  study  of  the  blood 
in    cases    of    mental    disorder    cannot     be    over-estimated. 


CAUSATION  OF  INSANITY  29 

Constipation  is  not  only  a  common  symptom  in  the  insane, 
but  it  is  the  rule  rather  than  the  exception  to  find  a  history  of 
prolonged  constipation  before  the  mental  disorder  supervened. 
For  years  the  blood  may  have  been  loaded  with  effete  material, 
and  is  it  to  be  wondered  at  that  the  nervous  system,  together 
with  other  systems  of  the  body,  finally  becomes  disorganised 
as  a  result  ?  Much  valuable  work  is  being  done  in  the  in- 
vestigation of  this  subject,  and  it  is  undoubtedly  a  field  of  study 
which  will  amply  repay  the  worker.  Perhaps,  after  all,  the 
causation  of  much  mental  disorder  is  not  so  intricate  and  com- 
plicated as  has  been  supposed  ;  and  it  may  be  that  while 
we  have  been  groping  in  the  dark  with  metaphysicians,  the 
key  to  the  problem  has  been  lying  under  our  very  hands. 
Let  there  be  no  misapprehension  ;  the  suggestion  is  no  new 
one  ;  it  may  well  be  that  its  revival,  assisted  by  later  scientific 
methods,  may  discover  much  that  escaped  those  who  have 
gone  before.  May  it  not  be  that  much  of  the  growing  increase 
of  mental  disorder  is  to  a  certain  extent  due  to  our  mode  of 
living  :  no  time  for  proper  meals,  no  time  for  necessary  exercise, 
no  time  for  attending  to  health  ;  the  race  for  life  is  too  keen, 
until  finally  we  perish  in  the  product  of  our  own  metabohsm  ? 

The  subject  of  direct  stresses  need  not  be  further  pursued, 
as  clearly,  if  the  damage  to  the  brain  is  severe  enough,  there 
will  be  some  mental  disorder  as  a  result,  no  matter  how  stable 
the  nervous  system  of  the  patient  may  originally  have  been. 
With  the  indirect  stresses  the  matter  is  different,  for  they  act 
much  more  readily  on  the  unstable  than  on  the  individual 
with  a  sound  nervous  system.  These  are  of  varied  kinds,  and 
include  such  factors  as  anxiety  and  worry,  financial  and 
domestic  difficulties,  misdirected  education,  intemperance, 
syphiUs,  sexual  excesses,  etc.  Certain  occupations  seem  more 
favourable  for  the  development  of  mental  disease  than  others, 
and  especially  highly  speculative  businesses.  Successful  work, 
so  long  as  it  is  not  too  successful,  seldom  leads  to  mental 
disorder  ;  but  unsuccessful  work  shows  a  very  different  record. 

Metabolism. — This  subject  is  of  intense  interest  in  connection 
with  the  study  of  mental  diseases,  but  at  the  present  time 
Uttle  or  no  work  has  been  done.  We  are  still  in  doubt  whether 
mental  disorder  is  the  primary  condition  and  that  the  physical 
disturbances  follow,  or  whether  the  mental  aberration  is  the 


30  PSYCHOLOGICAL  MEDICINE 

result  of  metabolic  changes  in  the  body.  Probably  both 
conditions  may  arise,  but  it  seems  more  likely  that  in  the 
majority  of  cases  we  shall  find  the  physical  changes  arise 
first.  For  example,  in  women,  menorrhagia  or  metrorrhagia  is 
frequently  followed  by  exhaustive  nervous  symptoms,  and  this 
may  result  from  the  loss  of  some  constituents  of  blood,  such  as 
the  calcium  salts.  One  of  the  best  examples  of  metabolic  dis- 
order, giving  rise  to  mental  distm'bances,  is  seen  in  myxcedema. 

Goodall,  in  his  Presidential  Address,  delivered  in  the  section 
of  Neurology  and  Psychological  Medicine  of  the  British  Medical 
Association,  in  1911,  referred  to  the  probable  toxic  origin  of 
some  kinds  of  insanity.  Eeferring  to  the  bacteriological  work 
in  insanity,  he  states  : 

'  Summarising  the  work  of  the  past  twenty  years  I  should 
affirm  that  there  are  no  adequate  grounds  for  believing  that 
the  organisms  which  have  been  found  in  the  tissues  in  any  case 
of  insanity  play  more  than  a  secondary  role.  At  the  same 
time,  they  frequently  cause  death.  (We  fall  victims,  it  has 
been  said,  most  often  to  om-  secondary  infections.)  Though 
not  shown  to  be  of  prime  pathological  significance,  they  may 
yet  be  shown  to  be  the  cause  of  some  of  the  symptoms.  Much 
more  work  is  required  in  this  field,  and  better  methods  of 
cultivation  of  organisms  are  needed.' 

Passing  on  to  discuss  leucocytosis  in  mental  disorders,  he  says : 

'  The  outstanding  pathological  fact  which  indicates  a  toxic 
pathogenesis  for  some  of  the  psychoses  is  leucocytosis.  The 
condition  is  found  very  commonly  in  acute  and  recent  mental 
disorder,  and  in  states  of  exacerbation  dui'ing  chronic  insanity. 
The  most  recent  workers  in  this  field  are  Dide  and  Chenais, 
Klippel  and  Lefas,  Lepine  and  Popoff  in  France  ;  Lewis  Bruce 
and  C.  MacDowall  in  this  country  ;  Heilemann  in  Germany  ; 
Graziani  in  Italy.  I  believe  the  following  statements  are 
justified  by  much  personal  study  of  thi*  question  for  the  past 
three  years,  and  by  the  work  of  these  investigators.  The  total 
leucocyte  count  is  increased  in  varying  amounts  from  11,000 
to  30,000  per  cubic  milHmetre  in  acute  and  recent  mania  and 
melancholia  (senility  excluded),  and  in  the  periodic  exacerba- 
tions of  chronic  cases  of  the  same.  Should  the  count  fall  in 
the  course  of  the  disease  it  rises  agam  to  rather  above  normal 
towards  the  close  of  the  attack  in  cases  which  recover,  and 


CAUSATION  OF  INSANITY  31 

remains  fairly  high  on  recovery.  In  acute  mania  and  melan- 
choHa,  the  percentage  proportion  of  the  neutrophile  cells  is 
increased  in  the  early  phases  of  the  disease,  also  towards  the 
close  of  the  attack  when  recovery  is  to  take  place.  In  these 
disorders  a  low  total  count  and  a  fall  in  the  normal  percentage 
of  neutrophils,  if  maintained,  are  of  bad  recovery,  and  point 
to  the  onset  of  dementia.  As  regards  dementia  prsecox,  in 
the  active  phase  there  is  some  (but  no  considerable)  increase. 
in  the  total  number  of  leucocytes ;  neutrophils  are  diminished, 
and  lymphocytes,  mononuclears,  and  eosinophiles  increased. 
Cases  of  systematised  delusional  insanity  do  not  exhibit 
leuCocytosis. 

'  As  a  generalisation,  in  the  acute  and  recent  mental  disorders 
there  is  leucocytosis  with  percentage  increase  of  the  polynuclear 
cells  ;  id  the  subacute  and  chronic  ones  there  is  little  or  none, 
and  the  proportion  of  large  mononuclears  and  lymphocytes  is 
increased.  In  acute  mental  disorders,  absence  of  leucocytosis 
and  a  fall  in  the  percentage  proportion  of  polymorphs  go  with 
deficient  reaction,  and  are  an  unfavourable  indication,  as  is 
the  case  in  those  infectious  fevers  in  which  leucocytosis  is 
observed.     This,  from  the  standpoint  of  toxaemia,  is  significant.' 

Over- work. — Over- work  is  a  cause  which  must  be  received 
with  extreme  caution.  No  doubt  some  individuals,  either 
from  necessity  or  from  choice,  spend  their  days  in  steady 
work,  and  seldom  take  exercise  or  indulge  in  holidays.  In  pre- 
disposed persons,  this  may  end  in  a  mental  break-down.  Again, 
it  is  not  uncommon  to  meet  persons  of  humble  origin,  who  by 
means  of  incessant  work  manage  to  raise  themselves  into  some 
position  higher  in  the  social  scale.  They  reach  their  ideal 
only  to  find  that  they  must  be  failures,  as  they  lack  the  attri- 
butes which  are  necessary  for  success.  Governesses,  to  some 
extent,  belong  to  this  class.  The  calling  of  a  governess  is 
always  precarious,  her'  salary  is  often  a  mere  pittance  ;  and, 
as  years  go  by,  she  finds  herself  with  no  savings,  her  ac- 
complishments out  of  date,  and  nothing  but  the  workhouse 
before  her. 

There  are  no  factors  so  prone  to  produce  insanity  as  worry 
and  constant  anxiety.  Domestic  troubles  perhaps  fall  more 
heavily  upon  women,  whereas  financial  difficulties  and  pecuniary 
losses  chiefly  affect  the  male  sex. 


32  PSYCHOLOGICAL  MEDICINE 

Education. — The  question  of  education  and  its  relationship 
to  insanity  is  constantly  being  inquired  into  with  varying 
results,  hi  educating  a  child  we  must  remember  that  the 
mind  and  body  should  be  developed  together.  The  close  rela- 
tionship of  mind  to  body  is  fully  recognised  in  theory,  but  in 
practice  it  is  all  too  frequently  overlooked.  How  common  it 
is  to  see  a  brilliantly  intellectual  child  being  forced  along  to 
•pass  high  examinations,  while  the  developments  of  the  physical 
side  are,  for  the  time  being,  forgotten  !  When  it  is  realised 
that  this  very  brilliancy  probably  indicates  nervous  and  mental 
instabihty,  that  it  is  the  product  of  too  rapid  evolution,  its 
grave  import  will  be  better  understood.  Brilliancy  ought  to  be 
the  warning  note  to  the  parent  and  the  teacher  that  the  mental 
side  must  be  kept  back  until  the  physical  is  developed.  One 
of  the  main  reasons  of  mental  failure  in  the  young  is  too  rapid 
evolution,  in  which  case  the  child  matures  too  quickly.  The 
danger  here  is  instabihty  and  a  tendency  to  decay  early. 
Throughout  the  natv.ral  world  we  find  that  those  organisms 
which  develop  rapidly,  and  reach  maturity  in  a  comparatively 
short  time,  tend  likewise  to  degenerate  early,  and  that  their 
life-history  is  a  short  one.  Exactly  the  same  process  takes 
place  in  the  nervous  system  of  a  human  being.  For  stabiUty 
it  is  requisite  that  the  growth  and  development  should  be 
slow  and  steady  ;  and  if  from  any  cause  this  development  is 
too  rapid,  it  indicates  a  tendency  to  mental  instability,  and 
not  uncommonly  early  failure.  How  often  parents  might  be 
saved  from  disappointment  if  this  fact  were  only  grasped  and 
understood  !  It  is  by  no  means  an  uncommon  sight  to  see 
a  child,  who  is  considered  to  be  a  mathematical  genius  or  a 
marvel  in  some  other  subject,  being  exhibited  before  an  assem- 
blage of  admiring  friends.  The  outlook  for  development 
in  such  a  case  is  not  too  hopeful,  as  the  very  relations  seem  to 
be  hurrying  on  the  child  to  intellectual  ruin.  Every  endeavour 
should  be  made  to  retard  rapid  development ;  the  physical 
side  should  be  fully  attended  to,  as  it  is  largely  upon  the  bodily 
condition  that  the  stabihty  of  the  mental  faculties  will  depend. 
Wise  education,  where  the  mind  and  body  are  developed  to- 
gether, but  neither  at  the  expense  of  the  other,  is  rmdoubtedly 
one  of  the  best  preventives  of  insanity. 

Religion. — Kehgion,  according  to  the  popular    view,  is    one 


CAUSATION  OF  INSANITY  33 

of  the  chief  causes  of  insanity.  This  error^for  never  was 
there  a  greater  one — has  been  brought  about  by  confusing 
cause  with  effect.  No  doubt  it  is  very  common  to  find  rehgious 
subjects  playing  an  important  part  in  many  cases  of  insanity, 
but  it  is  not  the  cause  of  the  mental  disorder,  but  rather  the 
explanation  the  patient  gives  of  altered  feelings  and  thoughts. 
Take,  for  instance,  an  insane  mother,  who,  from  her  very 
mental  disorder,  is  no  longer  able  to  attend  to  and  look  after 
her  children,  and  who,  for  the  same  reason,  neglects  all  her 
household  duties  ;  sooner  or  later  she  will  begin  to  accuse  herself 
of  being  unnatural,  and  allege  as  the  reason  that  God  has 
forsaken  her,  and  that  she  is  lost  for  ever.  After  this,  if  she  reads 
her  Bible  at  all,  she  notes  and  emphasises  all  the  verses  which 
condemn  her,  and  ignores  the  chapters  which  might  lead  to  her 
comfort.  Eeligion  deals  with  the  '  unknown,'  and  it  is  to  the 
*  unknown  '  we  appeal  for  explanation  when  a  disorder  which 
we  fail  to  recognise  as  an  illness  overtakes  us.  It  is  usually  the 
conscientious  individual  who  looks  to  religion  for  his  explana- 
tion ;  others  turn  to  hypnotism,  mesmerism,  electricity,  and 
the  like.  Thus  we  see  that  in  the  vast  majority  of  cases  religion, 
fer  se,  does  not  produce  insanity.  Nevertheless  there  are  a  few 
patients  whose  mental  break-down  dates  from  an  attendance 
at  some  emotional  rehgious  revival.  In  the  enthusiasm  of 
conducting  a  mission  it  is  apt  to  be  forgotten  that  there 
are  certain  unstable  inidividuals  who  will  be  attracted  by 
the  services.  Emotional  excitement  is  either  encouraged  or 
not  checked,  with  the  result  that  this  excitement  passes  on 
to  acute  mania  in  these  predisposed  persons.  Eeligion  is 
a  powerful  factor  in  the  life  of  most  individuals,  but  it  wants 
careful  and  judicious  handling  ;  otherwise  that  which  ought  to 
generate  good  may  be  the  exciting  cause  of  an  illness  which 
may  terminate  in  dementia. 

Alcohol. — Alcohol  stands  in  the  first  rank  as  a  factor  in 
the  production  of  insanity.  It  is  not  only  marked  intem- 
perance that  has  to  be  considered,  for  the  quantity  of  alcohol 
that  any  given  person  can  take  without  producing  intoxica- 
tion varies  enormously,  but  constant  '  nipping '  is  far  more 
damaging  to  the  nervous  system  than  bouts  of  drunkenness. 
In  the  individual  alcohol  acts  as  a  direct  poison,  and  sooner 
or  later  leads  to  impairment  of  the  mental  faculties,  or  maybe 

3 


34  PSYCHOLOGICAL  MEDICINE 

definite  brain  disorder.  Further,  in  the  famihes  of  alcoholic 
parents  nervous  diseases  of  all  kinds  appear  ;  the  child  may 
be  imbecile  from  birth,  or  may  early  develop  epilepsy,  and  in 
time  may  help  to  swell  the  already  large  number  of  insane. 
Children  of  alcoholic  parents  are  not  uncommonly  vicious  in 
their  habits  and  criminal  in  their  tendencies.  This  subject 
will  receive  more  detailed  consideration  in  a  subsequent  chapter, 
for  as  an  individual  cause  of  mental  disorder  alcohol  stands  a 
long  way  in  front  of  any  other. 

Syphilis. — Syphilis  may  be  a  predisposing  or  exciting  cause 
of  insanity,  and  will  be  fully  dealt  with  in  a  subsequent  chapter. 

Sexual  Excess. — With  regard  to  sexual  excesses,  these  pro- 
duce varying  results  in  different  individuals,  for  that  which  is 
excess  in  one  person  may  not  be  so  in  another.  Nevertheless, 
it  is  an  important  factor  in  the  production  of  nerve  exhaustion 
and  its  usual  concomitants. 

Masturbation. — ^Masturbation  in  both  sexes  is  closely  con- 
nected with  insanity  ;  in  certain  unstable  individuals  it  may 
be  the  exciting  cause,  but,  generally  speaking,  excessive  self- 
abuse  is  more  commonly  a  symptom  of  mental  disorder  than 
a  cause.  It  is  frequently  found  in  quite  young  children,  and 
requires  most  careful  treatment. 

Physical  Disease.' — Physical  disease  may  so  interfere  with 
the  nutritional  economy  of  the  organism  that  insanity  results. 
The  delirium  of  fever  may  develop  into  a  true  mania  ;  in 
fact,  a  temporary  insanity  or  mental  aberration  may  pass  on 
to  a  more  permanent  mental  disorder.  This  is  seen  with 
fever,  intoxication  from  alcohol,  with  anaesthetics,  and  in 
other  conditions. 

Sex. — Sex  plays  a  certain  part  in  the  causation  of  mental 
disorder,  as  the  stresses  vary  in  men  and  women.  Males 
suffer  chiefly  from  worry  and  anxiety  and  excesses  of  all 
kinds,  whereas  the  stress  in  the  case  of  the  female  is  largely 
connected  with  the  reproductive  functions.  The  onset  of 
menstruation  at  puberty,  the  monthly  nisus,  pregnancy, 
lactation,  and  the  climacteric  are  all  periods  of  severe  stress, 
and  in  unstable  women  may  be  the  determining  factors  in 
bringing  about' a  mental  breakdown.  There  are  more  insane 
women  in  the  world  than  insane  men,  but  this  is  in  some 
way  accounted  for  by  the  female  population  being  greater 


CAUSATION  OF  INSANITY  35 

than  the  male  ;  and  further,  fatal  disorders,  such  as  general 
paralysis  of  the  insane,  are  more  rife  among  men  than  women. 

Periods  of  Life. — We  now  pass  on  to  consider  the  various 
periods  of  life,  and  in  what  way  they  may  play  a  part  in  pro- 
ducing mental  disorder.  Throughout  the  early  years  of  a 
child's  life  it  ought  to  acquire  certain  attributes  in  a  fairly 
definite  order.  In  the  first  place,  the  microkinetic  or  spon- 
taneous uncontrolled  movements  of  infancy  slowly  disappear, 
the  child's  movements  are  regulated  and  controlled,  and 
are  adapted  to  its  wants  and  the  requirements  of  its  environ- 
ment. As  months  and  years  pass  along  we  see  the  develop- 
ment of  the  emotions,  memory,  attention,  control,  morality, 
and  reason  taking  place.  Hughlings  Jackson  has  pointed  out 
that  as  evolution  in  the  brain  advances  there  are  '  increasing 
complexity  '  (differentiation)  and  '  increasing  definiteness ' 
(specialisation).  Now,  anything  which  interferes  with  this 
evolution  tends  to  produce  mental  disorder  by  arresting 
mental  development.  For  example,  an  unstable  child,  whose 
parents  are  of  the  neurotic  type,  may  suffer  from  convulsions 
during  the  process  of  teething.  These  nerve  storms  may 
become  a  habit,  and  if  occurring  frequently  may  interfere  with 
the  mental  evolution,  and  imbecility  may  result.  Some 
children  grow  up  without  acquiring  such  attributes  as  control 
and  morality,  and  when  they  reach  puberty,  if  not  before, 
their  deficiency  may  give  rise  to  grave  breaches  of  the  social 
code  of  laws. 

Thus  in  early  life  mental  disorder  may  result  from  failure 
of  evolution  ;  the  child  never  acquires  its  full  complement  of 
faculties  ;  the  body  develops,  but  the  mental  growth  does  not 
keep  pace  with  it.  On  the  other  hand,  insanity  may  arise 
through  dissolution  taking  place  in  the  highest  centres.  The 
law  of  dissolution  of  the  nervous  system  is  that  the  latest 
acquired,  that  is  to  say  the  least  organised,  attributes  dege- 
nerate first.  This  law  holds  good  whether  one  is  dealing  with 
the  motor,  sensory,  or  intellectual  attributes.  The  powers 
of  reasoning,  control,  and  attention  are  early  lost  in  insanity. 
Mental  dissolution  may  take  place  at  any  period  of  life,  and 
may  be  rapid  or  slow  in  its  course  ;  but,  if  it  persists,  it  ulti- 
mately ends  in  weak-mindedness.  In  early  life  the  mental 
disorder  may  be  due  to  congenital  defects.     The  child  may 


36  PSYCHOLOGICAL  MEDICINE 

lack  the  sense  of  sight  or  hearing,  or  both,  and  in  consequence 
has  difficulty  in  acquiring  knowledge.  Puberty  is  a  period 
of  exceptional  stress,  especially  in  the  female,  and  the  appear- 
ance of  the  reproductive  functions  in  certain  predisposed 
persons  may  prove  too  severe  a  strain  on  the  organism,  and 
an  attack  of  insanity  results.  At  the  climacteric,  again,  when 
the  power  of  reproduction  disappears,  profound  changes  take 
place.  The  bodily  and  mental  functions  are  slowed,  and  life 
is  less  active,  but  before  this  takes  place  there  is  a  period  of 
peculiar  stress  which  may  lead  to  a  mental  breakdown.  With 
old  age  the  brain,  together  with  the  rest  of  the  bodily  organs, 
begins  to  atrophy,  and  in  some  persons  the  degeneration  of 
brain  substance  seems  to  be  more  rapid  than  in  the  tissues 
elsewhere.  As  in  all  forms  of  dissolution,  it  is  the  highest 
control  that  fails  first,  so  that  with  senility  it  is  not  uncommon 
to  see  defects  of  the  moral  sense.  With  old  age  the  insanity 
may  be  of  any  kind  ;  some  individuals  suffer  from  a  pro- 
gressive dementia,  while  others  have  a  temporary  mental 
disorder  similar  to  that  which  may  occur  at  any  other  period 
of  life. 

To  sum  up,  we  shall  find  that  as  a  general  rule  the  more 
marked  the  neurotic  inheritance  in  the  parents,  the  greater 
is  the  instability  in  the  offspring,  and  the  more  likely  the 
child  is  to  have  symptoms  of  mental  disorder  early  in  life. 
Curiously  in  some  families  there  seems  to  be  an  inherited  ten- 
dency always  to  break  down  at  the  same  period  of  life.  While 
on  the  subject  of  inherited  tendency,  a  moment's  consideration 
should  be  devoted  to  the  question  whether  there  is  such  a 
condition  as  an  Insane  Diathesis  ;  that  is  to  say,  whether 
there  are  individuals  who  from  their  constitution,  psychical 
or  physical,  show  that  they  are  more  than  commonly  liable  to 
mental  disorder.  The  terms  *  temperament '  and  '  diathesis  ' 
have  been  used  variedly  by  different  writers,  so  care  must  be 
exercised  in  noting  the  meaning  here  attached  to  them. 

Habit. — In  some  instances  insanity  is  secondary  to  some 
mental  change ;  in  other  words,  it  may  be  a  terminal  state. 
Elsewhere  we  have  pointed  out  the  influence  of  habit  and  the 
important  part  it  plays  in  the  mental  and  physical  life  of  the 
individual. 

Throughout  fife  we  are  acquiring  habits,  and  once  formed 


CAUSATION  OF  INSANITY  B7 

thej  automatically  influence  our  thought  and  conduct  in  the 
future.  Some  young  persons  foster  the  idea  that  those  about 
them  sHght  them,  give  them  the  cold  shoulder  and  generally 
neglect  them.  Slowly,  over  extended  years,  they  build  up  the 
pernicious  habit  of  looking  for  insults  ;  more  and  more  they 
distrust  the  intentions  of  others,  until  the  day  comes  when 
they  find  themselves  totally  out  of  touch  with  their  fellow-men. 
The  habit  of  indecision  is  another  example  which  in  time  may 
be  difficult  to  eradicate  and  yet  if  uncorrected  may  seriously 
affect  the  judgment. 

In  all  illness  there  is  a  tendency  for  the  patient  to  form  habits 
of  thought  and  action  during  the  acute  or  sub-acute  stages  of 
that  illness.  Now  these  habits  are  apt  to  persist  long  after  th6 
illness  has  passed  away  and  may  in  time  so  alter  the  person's 
outlook  in  life  as  to  render  him  incapable  of  adapting  himself 
to  his  surroundings. 

Diathesis. — Dr.  Eayner,  in  Tuke's  '  Dictionary  of  }?sycho- 
logical  Medicine,'  defines  Insane  Diathesis  as  a  '  deterioration 
of  hrain,  inherited  or  acquired,  indicated  hy  peculiarities  of 
functions,  hy  tendencies  to  mental  disorder,  and  often  associated 
icith  hodily  stigmata.''  There  are  two  varieties  of  Insane 
Diathesis  :  (1)  shown  by  eaxlj  and  precocious  mental  and 
physical  evolution,  frequently  met  with  in  persons  of  genius  ; 
(2)  indicated  by  late  and  defective  evolution  with  some  moral 
and  intellectual  weakness.  In  the  latter  class  the  physical 
stigmata  are,  as  a  rule,  more  marked. 

One  cannot  fail  to  recognise  that  there  are  persons  whose 
natures  are  highly  hyper-sensitive,  to  whom  a  look  is  as  painful 
as  a  severe  rebuke  to  a  more  phlegmatic  individual.  Sensi- 
tiveness is  an  attribute  of  extreme  value,  for  it  is  largely  by 
it  that  we  keep  in  touch  with  those  about  us  ;  and  a  sensitive 
person  is  constantly  adapting  himself  to  his  environment. 
Nevertheless,  when  carried  to  extremes,  sensitivity  may  form 
the  basis  of  delusions  ;  a  sneer  may  be  seen  when  no  such 
expression  was  intended,  or  a  smile  may  be  distorted  into  a  look 
of  scorn.  Another  temperament  which  is  constantly  met  with  is 
the  over-active,  restless  individual,  never  quiet  for  one  moment, 
but  often  capable  of  doing  a  large  amount  of  work.  Such  a 
person  wants  longer  hours  of  repose  than  his  phlegmatic  and 
apathetic  brother  ;    he  runs  through  his  stock  of  energy  at  a 


38  PSYCHOLOGICAL  MEBICINE 

rapid  rate,  and,  if  he  neglects  to  take  proper  rest,  the  end  is 
disaster.     Again,  how  common  it  is  to  see  a  man  whose  thoughts 
and   actions   are   always   tinged   with   suspicion !     Doubt   of 
the  motives  of  others  seems  to  be  the  fundamental  idea  which 
dominates  his  life.     As  years  pass,  this  tendency  to  suspect 
everybody  and  everything  grows,  and  in  time  begets  delusions 
of   persecution.     Other  forms  of   constitution  might  be  men- 
tioned if  any  useful  purpose  were  served  ;  but  at  the  moment 
it  is  enough  to  show  that  there  are  variations  of  temperament, 
and  that  there  are  temperaments  which  maybe  called  dangerous, 
as  predisposing  to  mental  disorder.     Insanity  in  such  cases 
seems  to  grow  insensibly  out  of  the  normal  condition,  and  it  is 
often  very  difficult  to  say  when  the  line  that  divides  sanity  from 
insanity  has  been  crossed.     Observe,  for  example,  a  young  man, 
whose  conceit  and  self-complacency,  though  remarkable  and 
far  exceeding  those  of  his  fellows,  are  put  down  to  the  affecta- 
tion of  youth.     Unfortunately,  as  evolution  takes  place,  this 
egotism  is  not  tempered  by  the  wisdom  of  increasing  years, 
but  becomes  more  and  more  offensive  and  overbearing,  until 
finally  the  man  is  consumed  by  the  vanity  of  his  own  import- 
ance.    Such  an  individual,  sooner  or  later,  frequently  develops 
delusions  of  grandeur.     Probably  a  good  deal  might  be  done  in 
the  early  training  of  these  individuals  in  the  way  of  prophylaxis, 
and  we  will  refer  again  to  this  subject  when  dealing  with 
treatment. 

The  causes  of  mental  disorder  are  so  numerous  that  it  is 
impossible  to  review  them  fully  in  so  short  a  chapter.  All 
that  can  be  done  is  to  refer  to  those  factors  which  seem  to  be 
the  most  powerful  in  producing  insanity.  These  agencies 
may  act  on  the  developing  nervous  system,  and  impede  or 
entirely  check  the  mental  evolution,  or  they  may  operate  on 
the  matured  brain  and  destroy  it.  The  principles  of  the 
causation  of  disease  must  be  learnt,  and  the  student  is  then 
able  to  note  for  himself  the  innumerable  conditions  which  are 
detrimental  to  a  healthy  organism. 


39 


CHAPTEE  IV 

CLASSIFICATION  OF  INSANITY 

This  is  a  subject  which  has  exercised  the  minds  of  many 
writers,  and  dm-ing  the  past  century  numerous  classifications 
have  been  drawn  up.  Unhappily  each  of  them  must  be  con- 
sidered to  be  more  or  less  unsatisfactory.  Some  writers 
endeavour  to  classify  from  the  psychological  standpoint, 
and  to  name  insanities  according  to  whether  the  malady 
touches  more  closely  the  emotions  or  the  will.  For  example, 
Heinroth's  classification  rested  on  the  threefold  analysis  of 
the  mind  into — 

1.  Intellectual  Faculties,     -i 

2.  Moral  Dispositions.       -fc 

3.  The  Will  (including  the  propensities). 

Other  authorities  have  tried  to  form  a  classification  based 
upon  the  most  prominent  symptoms  of  each  disorder. 
Pinel  had  merely  four  divisions — 

(a)  Mania. 

(fe)  Melancholia. 

(c)  Dementia. 

(d)  Idiocy. 

Esquirol,  who  came  later,  made  five  divisions  : 

(a)  Lypemania.  This  is  a  disorder  of  the  faculties  with 
respect  to  one  or  a  small  number  of  objects,  together  with 
feelings  of  depression. 

(&)  Monomania.  This  is  similar  to  the  first  group,  but  in 
the  place  of  depression  there  is  excitement. 

(c)  Mania.  In  this  the  insanity  extends  to  all  kinds  of 
objects,  and  is  accompanied  by  excitement. 


40  PSYCHOLOGICAL  MEDICINE 

(d)  Dementia — weak-mindedness. 

(e)  Imbecility  and  Idiocy. 

Griesinger  recommended  a  very  small  classification,  which 
consisted  of  three  divisions — 

1.  Mental  depression  or  melancholia. 

2.  Mental  exaltation. 

3.  Mental  weakness. 

Other  writers  have  endeavoured  to  classify  mental  dis- 
orders from  the  oetiological  point  of  view,  i.e.  naming  the 
insanity  after  its  causations,  sach  as  Phtliisical  or  Alcoholic. 
At  the  Paris  Congress  of  1889  Morel  drew  up  a  classification 
which  was  partly  symptomatological  and  partly  setiological ; 
and  the  Statistical  Committee  of  the  Medico-Psychological 
Association  of  Great  Britain  and  Ireland  have  dra\vn  up  a 
classification  upon  the  same  hues. 

During  recent  years  Kraepelin's  classification  has  been 
largely  used.  It  is  a  comprehensive  scheme,  and  one  that 
deserves  careful  study.  It  may  be  somewhat  compHcated  in 
some  of  its  divisions,  but  it  certainly  is  qaite  one  of  the  best 
classifications  which  we  have  at  the  present  time.  His 
scheme  is  as  follows  ; 

I.  Infection  Psychoses. 

(a)  Fever  delirium. 
(&)  Infection  delirium. 

(c)  Psychoses  characteristic  of  the  post-febrile 
period  of  infectious  diseases. 

in.  Exhaustion  Psychoses. 

(a)  Collapse  dehrium. 

(&)  Acute  confusional  insanity. 

(c)  Acute  dementia  and  hypochondriasis. 

{d)  Acquired  neurasthenia. 

III.  Litoxication  Psychoses. 
A.  Acute  Intoxications. 


1,  Alcoholism.  •/ 


CLASSIFICATION  OF  INSANITY  41 

B.  Chronic  Intoxications. 

'  (a)  Acute   alcoholic  intoxi- 
cation. 
(6)  Chronic  alcoholism. 

(c)  Delirium  tremens. 

(d)  Alcoholic  delusional  in- 
sanity. 

(e)  AlcohoUc  paranoia. 
^  (/)    Alcoholic  pseudoparesis. 

2.  Morphinism. 

3.  Cocainism. 

IV.  Thyroigenous  Psychoses. 

A.  Myxoedematous  Insanity. 

B.  Cretinism.  ,      .      , 

V.  Dementia  Prsecox. 

(a)  Hebephrenic  form. 

(&)  Catatonic  form. 

(c)  Paranoid  form.  .  .  , 

VI.  Dementia  Paralytica. 

VII.  Organic  Dementia. 

(a)  Diffuse  lesion. 
(&)  Locahsed  lesion. 

VIII.  Involution  Psychoses. 

(a)  Melancholia. 
(&)  Senile  dementia. 

IX.  Maniacal-depressive  Insanity. 

(a)  Maniacal  states. 
(6)  Depressive  states, 
(c)  Mixed  states. 

X.  Paranoia. 

XI.  General  Neuroses. 

(a)  Epileptic  insanity. 
(fe)  Hysterical  insanity, 
(c)  traumatic  neuroses. 


42  PSYCHOLOGICAL  MEDICINE 

XII.  Constitutional  Psychopathic  States. 

(a)  Congenital  neurasthenia. 
(6)  Obsessive  insanity. 

(c)  Impulsive  insanity. 

(d)  Contrary  sexual  instincts. 

XIII.  Defective  Mental  Development. 

(a)  Imbecility. 
(6)  Idiocy. 

Some  authors  have  attempted  to  divide  insanity  into  two 
classes  ;  namely,  curable  and  chronic.  This  is  not  a  very 
useful  classification,  as  at  the  present  time  the  term  '  chronic  ' 
is  used  in  a  sense  which  appears  to  the  writer  to  be  incorrect. 
Most  authorities  in  mental  disease  use  the  word  '  chronic  '  as 
indicating  that  an  insanity  has  lasted  a  certain  time.  The 
term  '  chronic '  as  apphed  to  disease  does  not,  however, 
necessarily  imply  that  it  has  lasted  through  some  given 
antecedent  period.  It  suggests  rather  incm'abihty.  Some 
disorders,  such  as  dementia  prsecox,  paranoia,  certain  cases 
of  mania  and  melanchoha,  and  many  other  insanities,  are 
chronic  from  the  first,  and  it  is  only  a  question  of  diagnosis 
to  recognise  that  this  is  the  case.  In  dealing  with  physical 
diseases  we  do  not  hesitate  to  affirm  that  a  patient  ex- 
hibiting certain  symptoms  is  suffering  from  chronic  inter- 
stitial nephritis,  notwithstanding  that  he  has  only  recently 
complained  that  he  is  out  of  health.  Why  should  a  different 
test  be  apphed  to  mental  disease  ?  Experience  teaches  us 
that  there  are  some  cases  of  mania  which  at  the  very  outset 
exhibit  marked  symptoms  of  degeneracy  ;  and  sm'ely,  correctly 
speaking,  being  incurable,  these  ought  to  be  classed  as  chronic 
from  the  very  beginning.  At  first  many  mistakes  wiU  be  made  ; 
patients  who  were  considered  to  be  incm'able  will  sometimes 
recover.  Every  physician  must  make  mistakes,  but  probably 
the  use  of  the  term  '  chronic  '  in  the  manner  above  suggested 
wiU  induce  keener  observation  and  greater  accm'acy  in  the 
examination  of  patients.  It  need  hardly  be  added  that  it  is 
often  neither  necessary  nor  advisable  to  inform  the  friends  of 
a  patient  that  their  relative  is  thought  to  be  chi'onically 
insane.     Chcumstances    must    guide   action   in   this   respect  ; 


CLASSIFICATION  OF  INSANITY  43 

indeed,  the  physician  will  seldom  err  if  he  regulates  his 
attitude  and  action  in  cases  of  mental  disorder  by  the  same  con- 
siderations as  would  be  applicable  to  a  case  of  physical  disease. 

Several  attempts  have  been  made  to  formulate  a  scheme  of 
classification  on  a  pathological  basis,  but  the  results  have  been 
most  disappointing.  Still,  the  student  must  be  given  some 
system  upon  which  he  may  work,  some  scaffold  upon  which 
he  may  build.  The  writer  does  not  wish  to  add  any  new 
classification  to  the  aheady  large  number,  but  wUl  use  the 
following  general  scheme,  which  he  has  drawn  up  from  the 
classifications  of  other  authors  : 

1.  Mania  and  States  of  Excitement. 

2.  Melancholia  and  States  of  Depression. 
-    3.  Mental  Stupor. 

4.  Chronic  Delusional  Insanity  (Paranoia). 

5.  Dementia  Praecox. 

6.  Dementia,  secondary  and  organic. 

(Puerperal. 
Climacteric. 
Senile.    Arteriopathic. 

f  Alcoholism. 


Intoxication 
Psychoses. 


Morphinism. 

Cocainism. 

Plumbism. 


9.  General  Paralysis  of  the  Insane. 


10.  Exhaustion 
Psychoses. 


Acute  Hallucinatory  Insanity. 
Neurasthenia.    Chronic  Nerve  Exhaustion. 


(Epilepsy  and  Insanity. 
Hysteria  and  Insanity. 
Traumatic  Neuroses. 

12.  Obsessional  Insanity.     Psychasthenia. 

13.  Insanity  associated  with  Physical  Diseases. 

(Moral  Insanity, 
Imbecility,  and 
Idiocy. 

This   scheme   has   the   great    objection   that   it   is   partly 
symptomatological    and    partly    aetiological.     The    writer    is 


44  PSYCHOLOGICAL  MEDICINE 

aware  that  this  method  of  arrangement  is  condemned  by  some 
authorities  ;  for  to  name  a  disease  after  its  supposed  cause  is 
in  many  ways  unscientific,  as  we  may  be  describing  over  and 
over  again  the  same  complaint  under  a  different  name.  For 
example,  under  puerperal  insanity,  mania  and  melancholia 
are  again  referred  to,  notwithstanding  that .  they  have  been 
aheady  described  elsewhere.  Gn  the  other  hand,  provided 
that  care  is  taken  to  point  out  that  no  new  disease  is  being 
recounted,  from  a  clinical  aspect  this  method  has  its  advan- 
tages. The  practitioner  or  student  can  more  readily  refer  to 
the  disorders  which  may  occur  at  any  special  period,  and  the 
course  of  the  illness  can  more  easily  be  depicted.  Mania 
associated  with  senility  differs  in  some  respects  from  the 
mania  of  early  life  ;  some  symptoms  which  might  have  been 
neglected  in  the  adolescent  are  of  great  importance  in  the 
aged.  Every  classification  of  insanity  is  apt  to  confuse  the 
student  unless  he  carefully  studies  the  basis  on  which  it  has 
been  drawn  up.  The  most  simple,  and  in  many  ways  the 
most  scientific,  form  of  classification  of  mental  disorder  would 
be  one  consisting  of  three  divisions  : 

'-1.  Failure  of  evolution. 

.  2.  Derangement  of  normal  mental  functions. 

^3.  Dissolution  or  Dementia. 

Many  persons  are  insane  because  their  brain  is  not  equipped 
with  a  sufficient  number,  of  nerve-cells  or  a  proper  complement 
of  association-fibres.  Others  start  life  with  a  normal  supply, 
but  either  from  disease  or  decay  they  become  reduced  in 
number  or  activity.  Between  this  state  of  amentia  and 
dementia  there  are  many  stages.  The  nervous  mechanism 
may  be  damaged  temporarily  and  recover,  or  it  may  slowly 
degenerate  during  a  period  of  months  or  years.  Now,  we 
might  give  a  different  name  to  every  phase  of  this  disintegra- 
tion, according  to  the  clinical  aspect.  Buch  are  the  difficulties 
which  he  in  the  path  of  the  man  who  seeks  to  devise  a 
scientific  classification.  It  is  on  these  grounds  that  the  writer 
prefers  to  use  a  purely  utilitarian  arrangement,  one  that  is 
useful  to  the  teacher  and  comprehensible  to  the  student. 


45 


CHAPTER  V 

GENERAL    SYMPTOMATOLOGY 

Before  passing  on  to  consider  distinct  forms  of  mental 
disease,  it  may  be  helpful  to  the  student  to  devote  some  pages 
to  the  study  of  those  various  symptoms  which  are  commonly 
met  with  in  the  insane.  In  this  way  much  repetition  will  be 
avoided,  and  the  advantage  gained  of  famiHarising  the  student 
with  the  general  aspects  of  the  subject,  and  so  facilitating  for 
him  the  diagnosis  of  mental  disorder,  always  a  difficult  duty 
to  the  novice.  Once  more — a  wearisome  but  necessary  re- 
iteration— let  the  beginner  be  encouraged  to  approach  the 
study  of  mental  disease  in  the  same  attitude  of  mind  as  he 
would  engage  upon  the  study  of  medicine  or  surgery.  Let 
the  principles  of  the  subject  first  be  grasped  and  thoroughly 
mastered  ;  afterwards  the  acquisition  of  detail  will  be  found 
to  be  comparatively  easy.  There  are  fundamental  principles 
which  must  be  learned  before  the  student  can  hope  to  under- 
stand mental  disease  ;  it  is  the  ignorance  of  these  principles 
which  makes  insanity  appear  so  obscure  and  incomprehensible 
a  subject. 

In  the  early  stages  one  must  not  expect  to  find  too  pro- 
found a  mental  change.  Insanity,  like  everything  else,  has  a 
beginning ;  and,  as  a  rule,  it  develops  by  degrees  so  slow  and 
subtle  that  the  physician  who  only  recognises  glaring  symp- 
toms of  mental  aberration  will  fail  to  recognise  the  disorder 
while  in  its  most  curable  state.  Minor  symptoms  must 
receive  their  due  amount  of  attention,  and  not  be  brushed 
aside,  as  they  frequently  are,  or  ignored  as  being  of  little 
consequence.  The  student  can  study  mild  forms  of  mental 
disorder  in  himself,  and  he  will  find  such  introspection  of 
great  assistance  in  comprehending  the  more  advanced  dis- 
orders of  others. .  For  example,  we  all  have  experienced 
days  on.  which  we  have  had  feelings  of    malaise    and  mild 


46  PSYCHOLOGICAL  MEDICINE 

depression,  when  small  troubles  have  seemed  vast,  when  mole- 
hills have  become  mountains.  On  such  days  the  business 
man  feels  that  ruin  is  staring  him  in  the  face  ;  the  worker 
feels  that,  no  matter  how  hard  he  may  work,  success  is  not 
to  be  his.  Accompanying  these  feelings  there  is  a  restlessness 
and  loss  of  attention  ;  the  sufferer  derives  temporary  consolation 
from  the  sympathy  of  others,  but  relapses  into  despondency 
when  solitude  returns.  Picture  yourself  always  in  this  state, 
and  imagine  your  worst  moments  as  about  equal  to  the  better 
moments  of  the  acute  melancholiac  ;  you  will  then  have  some 
idea  of  what  despair  really  means.  Or,  when  much  fatigued — 
if  quiet  introspection  is  at  such  a  time  at  your  command — ^try 
to  read  a  scientific  book  or  write  a  letter,  observing  your  mental 
state  when  a  word  or  question  is  addressed  to  you.  Or,  again, 
when  you  are  distracted  by  the  fear  of  some  impending 
disaster,  when  your  thoughts  seem  confused,  and  constant 
walking  about  seems  your  only  relief,  try  to  sit  down  for 
an  hour  or  two  ;  you  will  then  in  a  feeble  way  realise  what 
the  insane  man  has  to  bear  when  he  tries  to  control  his 
feehngs.  Thus  we  learn  that  what  we  term  mental  disorder 
is  not  so  much  the  development  of  something  new  as  the 
persistence  of  certain  symptoms  which  in  the  normal  mind 
appear  but  seldom  and  for  a  short  space  of  time.  If  a  man 
gives  way  to  an  outburst  of  temper,  his  friends  may  regret 
it,  but  they  do  not  consider  it  a  symptom  of  insanity  ;  but 
suppose  that  his  bad  temper  becomes  chronic,  and  he  is 
persistently  irritable,  the  probability  is  that  a  physician  will 
be  called  in  to  examine  his  mental  condition. 

We  may  all  at  some  time  in  our  life  conclude,  rightly  or 
wrongly,  that  the  disposition  of  a  particular  person  is  un- 
friendly towards  us  ;  yet  no  one  would  think  of  casting  a  doubt 
on  our  mental  state  if  we  suggested  our  suspicions  to  him  ; 
but  if  we  continually  suspect  the  motives  and  intentions  of 
others,  and  shape  our  conduct  accordingly,  it  will  not  be  long 
before  we  are  looked  upon  as  of  unsound  mind.  Unless  a 
physician  is  on  the  watch  for  symptoms,  he  will  either  over- 
look or  misconstrue  them.  Eemember  the  possibility  of 
mental  disorder  in  examining  your  various  cases.  No  one 
can  diagnose  what  is  not  present  to  his  mind  ;  and,  after  all, 
unsoundness  of  mind  is  not  an  uncommon  condition.    More 


GENERAL  SYMPTOMATOLOGY  47 

cases  of  mild  disorder  of  the  mind  are  to  be  met  with  in  general 
practice  than  is  commonly  imagined,  and  it  is  as  important 
to  diagnose  and  treat  mild  distm'bances  as  the  more  ad- 
vanced stages.  Indeed,  in  many  ways  it  is  more  important ; 
for  the  earlier  condition  is  more  curable,  and  prompt  treat- 
ment may  arrest  its  development.  It  is  a  mistake,  and  im- 
proper, to  apply  the  term  '  insanity  '  to  these  mild  disorders  ; 
but,  as  a  rule,  there  is  no  objection  to  informing  the  patient 
and  his  relatives  that  the  symptoms  complained  of  are  nervous 
in  their  origin  and  require  very  decided  treatment. 

Again,  it  must  not  be  forgotten  that  certain  symptoms 
standing  alone  may  be  of  no  diagnostic  value,  but  when  asso- 
ciated with  others  they  may  be  of  great  importance.  For 
instance,  a  condition  of  general  exaltation  may  indicate  merely 
a  mental  state  which  is  common  to  many  forms  of  insanity  ; 
but  associated  with  marked  pupillary  changes,  and  hesitancy 
of  speech,  it,  in  all  probability,  points  to  some  organic  disease 
of  the  brain.  There  are  physical  as  well  as  mental  symptoms 
to  be  considered  when  diagnosing  or  treating  insanity,  and  it 
will  be  convenient  to  divide  symptoms  under  these  two  heads. 
The  writer  always  adopts  this  plan,  and  it  will  be  found  of 
practical  value  in  examining  cases  of  mental  disorder  ;  other- 
wise important  symptoms  may  be  overlooked.  Always  carry 
out  your  examination  in  a  methodical  manner.  Investigate 
each  case  separately,  carefully  noting  the  presence  of  disease 
in  any  organs  of  the  body.  It  is  usually  advisable  to  ask  the 
patient  regarding  his  physical  health  first,  for  in  this  way  the 
suspicious  person  may  be  thrown  off  his  guard  and  become 
more  confidential ;  and,  in  any  case,  questions  regarding  his 
body  do  not  provoke  surprise  in  a  patient  who  might  be  much 
alarmed  if  the  interview  began  by  an  examination  pointing  to 
hallucinations  or  delusions.  Eemember,  also,  that  the  physi- 
cian has  not  merely  to  determine  that  a  man  is  insane — a 
layman  can  usually  do  that — ^he  has  also  to  endeavour  to 
find  out  the  cause  of  the  malady.  Insanity  is  not  uncommonly 
the  result  of  some  physical  disease,  in  which  case  the  prognosis 
largely  depends  on  the  curability  of  that  disease.  Thus  we 
see  how  important  it  is  to  be  thorough  in  our  examination, 
and  to  ascertain,  if  possible,  whether  the  mental  symptoms  are 
secondary  to  the  physical  or  vice  versa. 


48  PSYCHOLOGICAL  JMEDICINE 

^  Disorders  o£  Sensation.-^Disorders  of  sensation  are  of  three 
kinds  :  anaesthesia,  hyperaesthesia,  and  paraesthesia.  The  cuta- 
neous surfaces  can  be  tested  by  response  to  the  prick  of  a  pin. 
Stoddart  has  pointed  out  that  cutaneous  anaesthesia  occurs  most 
commonly  in  stuporose  and  confusional  states.  A  very  exten- 
sive anaesthesia  is  generally  fomid  in  patients  recovering  from 
acute  mania,  but  it  is  usually  only  of  a  temporary  nature  and 
may  disappear  in  a  few  days.  The  sense  of  liearing  is  deficient 
in  some  cases  of  insanity,  especially  in  patients  with  arterio- 
sclerotic changes.  The  deaf  are  more  prone  to  mental  disorder, 
and  even  in  the  sane  this  symptom  tends  to  produce  suspicion 
in  the  sufferer.  The  visual  sense  may  be  lessened  and  the  visual 
field  contracted.  The  colour  sense  is  usually  normal,  except 
in  the  exhaustion  psychoses  and  in  arteriosclerotic  disease 
when  it  may  be  defective,  especially  for  some  shades  of  blue 
and  possibly  green.  The  senses  of  taste  and  smell  are  dimin- 
ished in  dementia,  idiocy  and  in  the  exhaustion  psychoses, 
and  at  times  in  general  paralysis.  The  acuteness  of  taste  may 
be  lessened  or  taste  sensations  may  be  altered  ;  this  is  seen  in 
the  voracious  appetite  of  some  patients  (Boulimia).  These 
persons  may  consume  ah  manner  of  filth.  ^\Tien  it  is  possible 
to  ehcit  why  these  things  are  eaten,  the  reason  sometimes  given 
by  the  patient  is  that  he  has  a  constant  feeling  of  faintness  or 
nausea  and  that  matter  of  all  kind  allays  this  sensation.  The 
taste  is  best  tested  by  solutions  of  salt,  sugar  and  quinine. 

The  visceral  sense  may  be  affected,  as  observed  by  changes 
in  the  ahmentary  tract.  The  appetite  may  be  changed  or 
there  may  be  an  actual  dislike  to  all  food.  Hypercesthesia, 
especially  of  the  sense  of  hearing,  is  very  marked  in  the  nerve 
exhaustion  cases ;  even  slight  noises  may  be  intolerable. 
The  pelvic  organs  may  be  hypersensitive,  or  owing  to  anaes- 
thesia of  the  hmbs  and  other  parts  of  the  trunk  there  may  be 
a  relative  hyperaesthesia. 

Increased  acuteness  of  sensation  in  these  parts  not  uncom- 
monly leads  to  delusions  regarding  them.  Parcesthesice  are 
more  readily  considered  under  illusions  and  hallucinations. 
In  conclusion,  w^hatever  may  be  the  cause  of  perverted  sensa- 
tions, whether  they  are  peripheral  or  central,  it  must  always 
be  remembered  that  altered  sensations  are  a  very  potent 
factor  in  the  production  of  delusions.     They  lead  to  an  altered 


GENERAL  SYMPTOMATOLOGY  49 

idea  of  self,  and  the  tendency  is  for  the  person  so  affected  to 
endeavour  to  account  for  the  changed  state  of  things.  This 
is  especially  the  case  when  the  organic  sensations  are  disturbed. 
A  word  of  warning  may  be  useful :  do  not  be  too  ready  to  class 
all  complaints  of  disordered  sensations  as  delusions.  Fre- 
quently patients  will  misinterpret  their  sensations,  and  it  is  the 
duty  of  the  physician  to  find  out,  if  possible,  whether  there 
is  any  organic  disease  to  account  for  the  symptoms.  A  good 
example  of  this  is  the  mental  aspect  met  with  in  some  cases 
of  locomotor  ataxy.  .Tabetic  patients  may  misinterpret  the 
ordinary  physical  symptoms,  and  may  explain  the  gastric  and 
other  crises  by  extraordmary  delusions. 

Disorders  of  Perception^l^Disorders  of  perception  are  met  with 
in  many  types  of  mental  disorder.  They  are  of  the  following 
Varieties  :  (a)  Imperception,  {b)  Hallucinations,  and  (c)  Illusions. 
Imyerceftion  occurs  most  commonly  in  arteriosclerotic  condi- 
tions. By  imperception  we  mean  a  state  in  which,  although  the 
individual  is  able  to  sense  objects  either  by  hearing,  seeing,  feel- 
ing, tasting  or  smelling,  he  cannot  state  what  these  objects  are  ; 
past  experience  seems  to  be  obhterated.  At  times  the  patient 
may  be  able  to  show  you  what  to  do  with  a  thing,  but  he  cannot 
tell  you  what  it  is.  Give  him  a  knife  and  he  may  tell  you  it  is 
a  thing  to  cut  with,  or  even  if  he  is  unable  to  give  you  this 
information  he  may  show  you  for  what  it  is  intended  to  be  used. 
There  are  various  degrees  of  imperception,  total  or  partial. 
The  dissolution  that  is  taking  place  closely  resembles  in  the 
inverse  order  the  imperception  of  childhood,  but  with  this 
difference,  that  tbe  child  has  potentiahties  of  acquiring  know- 
ledge, whereas  the  patient  with  arteriosclerotic  changes  is 
degenerating  and  is  losing  the  memory  of  experience  which 
he  once  possessed.  Imperception  or  agnosia,  as  it  is  sometimes 
called,  can  be  tested  in  many  ways,  either  by  single  articles 
such  as  a  key,  pen,  knife,  coins,  etc.,  for  visual  imperception  ; 
bells,  tapping  on  wood  or  china,  rmining  water,  etc.,  for  auditory 
imperception  ;  giving  the  patient  objects  to  hold  and  describe 
(with  eyes  blindfolded)  for  tactual  imperception  ;  and  tests 
for  taste  and  smell  for  imperception  of  these  senses.  If  these 
are  successfully  recognised  a  more  comphcated  series  of  tests 
can  be  made,  such  as  giving  the  patient  pictures  to  describe, 
and  for  the  finest  degrees  of  imperception  Stoddart  recommends 

4 


50  PSYCHOLOGICAL  MEBICINE 

a  children's  book  in  which  proverbs  are  clearly  depicted  in 
picture  form — '  Proverbs  old  newly  told.'  Another  condition 
which  occurs  in  the  same  disorders  as  imperception,  and  which 
is  closely  allied  to  it,  is  that  which  is  known  as  ideational  inertia, 
or  by  some  authorities  as  agnostic  perseveration.  It  is  a  state 
of  fatigue  and  is  best  explained  by  means  of  an  illustration. 
If  a  patient  is  shown  a  key  he  will  answer  correctly  ;  next  show 
him,  for  example,  a  penholder,  and  this  he  again  describes  cor- 
rectly ;  then  give  him  a  knife  and  he  will  say  that  it  is  a 
penholder,  and  to  each  article  now  shown  he  will  say  penholder. 
He  has  passed  into  a  state  of  fatigue,  and  is  now  unable  to 
get  away  from  the  idea  and  word  penholder. 

Hallucinations  and  Illusions 

Definition. — An  hallucination  has  been  defined  as  *  a  false 
perception  of  the  senses  without  an  external  stimulus,'  i.e.  we 
see,  hear,  feel,  taste,  or  smell  something  which  has  no  apparent 
external  origin.  If  a  face  or  light  is  seen  in  an  absolutely 
dark  room,  this  would  be  spoken  of  as  an  hallucination. 

An  illusion  is  a  false  perception  of  the  senses  with  an  ex- 
ternal stimulus.  For  example,  a  pattern  is  seen  on  the  carpet, 
and  is  taken  for  ^vriting  ;  or  the  wind  howling  in  the  chimney 
is  interpreted  into  the  sound  of  a  voice.  It  is  frequently  difficult 
to  decide  whether  the  sensory  distm'bance  is  in  reality  an 
hallucination  or  an  illusion,  but  illusions  are  probably  more 
common  than  pure  hallucinations. 

As  the  study  of  illusions  is  somewhat  simpler  than  that  of 
hallucinations,  their  various  forms  may  first  be  enumerated 
and  described.  There  are  two  main  divisions  of  illusions  : 
(1)  Passive,  (2)  Active.  The  Passive  Illusions  arise  from 
without,  and  are  largely  suggested  by  external  or  physical 
factors ;  whereas  the  Active  Illusions  arise  from  within  and 
are  due  to  expectancy. 

Professor  SuUy  classifies  illusions  in  the  following  way : 

Passive  Illusions 

1.  Exoneural,  determined  by — ■ 

(a)  Exceptional  external  arrangements,  e.g.  a  stick  immersed 
in  water  appears  to  be  bent. 


GENERAL  SYMPTOMATOLOGY  51 

(6)  Exceptional  relation  of  stimulus  to  organ,  e.g.  objects 
appear  smaller,  and  at  greater  distance,  when  one  eye  is  used 
than  when  we  use  both  eyes. 

(c)  Illusions  of  art. — Stereoscopic  effects  are  instances  of 
this  type  of  illusions,  for  by  means  of  the  stereoscope  we  get 
the  appearance  of  solidity  and  depth. 

{d)  The  "particular  forms  of  objects. — The  limbs  or  head 
may  seem  enormously  enlarged  or  greatly  contracted  under 
certain  conditions.  Drugs  such  as  hashish  will  produce  this 
effect. 

(e)  Tlie  points  of  similarity  of  objects. — An  illustration  of 
this  is  seen  in  errors  of  identity.  A  person  sees  a  resemblance 
to  his  friends  or  relatives  ia  the  faces^of  strangers.  Probably  all 
differences  and  defects  in  the  likeness  are  corrected  by  imagina- 
tion, just  as,  when  we  are  examining  printed  proofs  of  manu- 
script, we  are  apt  to  pass  over  wrongly  spelt  words,  for  we 
intuitively  correct  the  error  in  our  own  minds.  Mistaken 
identity  is  very  common  in  the  insane,  and  may  be  due  to 
some  error  of  refraction,  which  causes  a  blurring  of  outline  of 
the  features,  and  the  result  is  an  illusion. 

if)  The  reverse  illusions  of  orientation. — When  travelling 
by  train  at  night  it  is  often  very  difficult  to  decide  in  which 
direction  we  are  moving,  and  by  an  effort  of  imagination  we 
can  persuade  ourselves  that  we  are  moving  either  backwards 
or  forwards. 

2.  Esoneural,  determined  by — 
(a)  The  limits  of  sensibility  : 

(1)  Degree  of  stimulus. 

(2)  Number  of  stimuli. 

(3)  Fusion  of  stimuli. 

(4)  After-sensations. 

(5)  Specific  energy  of  nerves. 

(6)  Eccentric  projection. 

After-sensations  are  a  good  example  of  this  form  of  illusion. 
For  instance,  we  may  feel  the  rolling  of  a  ship  for  hours  after 
we  have  landed  ;  or,  in  the  case  of  eccentric  projection,  there 
may  be  apparent  feeling  in  the  toes,  notwithstanding  the  fact 
that  the  hmb  has  been  amputated.     This  latter  condition  can 


52  PSYCHOLOGICAL  MEDICINE 

be  explained  by  '  the  law  of  eccentricity,'  which  affirms  that 
we  refer  our  sensations  to  the  peripheral  endings  of  nerves. 
(b)  By  the  variatioii  in  sensibility  : 

(1)  Transient. — Illusions  due  to  the  exhaustion  of  the 
various  sense  organs. 

(2)  Comparatively  permanent  conditions. — Colour-blindness, 
conditions  of  more  or  less  permanent  hyperaesthesia,  anaesthesia, 
or  parsesthesia. 

Active  Illusions 

In  active  illusions  there  is  a  state  of  expectancy.  For 
instance,  when  standing  in  a  crowd  waiting  for  a  procession  to 
pass,  we  may  fancy  we  hear  the  music  of  the  band  long  before 
it  is  possible  for  it  to  reach  our  ears.  The  phenomena  seen 
by  various  individuals  at  seances  are  commonly  illusions  of 
this  type.  It  is  certainly  the  most  frequent  form  of  sensory 
disorder  met  with  in  the  insane.  In  describing  the  symptoms 
of  melancholia,  reference  will  be  made  to  the  part  played 
by  active  illusions.  In  fact,  in  all  forms  of  mental  disease 
expectancy  is  the  forerunner  of  many  sensory  disorders.  The 
maniac  sees  beauty  in  everything,  while  to  the  melancholiac 
all  is  gloomy  and  ugly.  What  we  expect  to  see  we  are  apt  to 
see,  whether  it  is  a  smile  or  a  scornful  look.  If  we  believe 
the  world  is  saying  things  against  us,  we  are  prone  to  hear 
disparaging  remarks.  In  a  word,  we  are  ready  to  be  deceived 
by  our  senses. 

Before  leaving  the  subject  of  illusions,  mention  must  be 
made  of  another  class  of  illusions  which  have  been  termed 
secondary  sensations.  Some  individuals  never  see  a  colour 
without  having  the  sensation  of  a  distinct  smell  which  always 
seems  to  accompany  that  particular  colour.  In  the  same 
way  sounds  may  be  associated  with  colours,  or  colours  with 
smells. 

Bleuler  has  divided  these  secondary  sensations  into  : 

1.  Sound  fhotisms.  Sensations  of  colour  accompanying 
sensations  of  sound. 

2.  Light  fhonisms.  Sensations  of  sound  from  perception 
through  light. 

j3.  Taste  fhotisms.     Sensations   of   colour   from  perception 
through  taste. 


GENERAL  SYMPTOMATOLOGY  58 

4.  Odour  fhotisms.  Sensations  of  colour  from  perception 
through  smell. 

5.  Pain  fhotisms.  Sensations  of  colour  from  perception 
of  pain,  temperature,  and  touch. 

Certain  of  the  insane  are  found  to  have  these  secondary 
sensations,  and  hitherto  no  satisfactory  explanation  has  been 
given  of  the  phenomena. 

To  revert  to  the  consideration  of  hallucinations  and  illu- 
sions. As  already  stated,  it  is  frequently  very  difficult  to 
decide  whether  we  have  in  a  given  case  to  deal  with  an 
hallucination  or  an  illusion,  for  it  is  often  by  no  means  easy 
to  say  whether  there  is  any  recognisable  external  stimulus. 
Professor  Ball  believes  that  even  an  illusion  involves  an 
■hallucination,  and  that  there  is  no  fundamental  difference 
between  the  two.  Therefore,  from  the  clinical  point  of  view,  it 
is  more  convenient  to  consider  them  together.  It  will  perhaps 
be  as  well  to  state  that  the  presence  of  hallucinations  and 
illusions  does  not,  'per  se,  constitute  insanity.  Many  sane 
persons  suffer  from  hallucinations — in  fact,  they  may  be 
able  to  produce  them  at  will ;  and  similarly  with  illusions, 
no  one  is  exempt  from  the  risk  of  being  in  this  way  deceived 
by  his  senses.  Hallucinations  and  illusions  are  common  in 
dreams  and  in  half-asleep  and  half-awake  states  (hypnagogic 
states).  Head  also  lays  stress  upon  their  presence  in  associa- 
tion with  certain  types  of  visceral  disease.  But  if  we  are  not 
to  rely  too  much  on  the  presence  of  hallucinations  as  a  test  of 
mental  disease,  we  must  not  under-estimate  their  importance 
when  associated  with  other  symptoms  of  insanity.  Hallucina- 
tions are  not  only  valuable  corroborative  evidence,  but  may 
prove  very  helpful  when  we  have  to  give  a  prognosis. 

As  a  general  rule  persistent  hallucinations  may  be  a  grave 
symptom,  and  a  physician  should  be  on  his  guard  not  to  give 
too  favourable  a  prognosis  regarding  a  patient  who  is  thus 
afflicted.  Further,  it  must  be  borne  in  mind  that  the  majority 
of  the  insane  who  suffer  from  hallucinations  treat  them  as  if 
they  were  realities  ;  for,  after  all,  how  can  they  distinguish 
between  normal  special  sense  sensations  and  the  abnormal  ? 
It  is  true  that,  if  the  illusions  are  indistinct  and  fleeting,  it 
may  be  possible  to  get  the  patient  to  ignore  them  ;  but  if 
they  are  vivid  and   oft-recurring,  he  will  almost  certainly  be 


;S4  '  PSYCHOLOGICAL  MEDICINE 

infltienced  by  them.     He  has  trusted  his  senses  in  the  past, 
and  why  should  he  discredit  them  now  ? 

Auditory  Hallucinations. — Auditory  hallucinations  are  the 
most  common  variety,  probably  owing  to  the  fact  that  we  use 
the  sense  of  hearing  by  night  as  well  as  by  day.  It  is  also 
the  most  liighly  developed  sense.  Auditory  hallucinations 
usually  begin  as  indefinite  sounds,  and  later  become  more 
organised — into  whisperings  and  definite  '  voices,'  or  they  may 
remain  as  rushing  or  roaring  sounds,  or  even  be  musical  in 
character.  If  they  become  organised  into  '  voices,'  commonly 
single  words  are  heard  at  first,  and  at  a  later  stage  sentences. 
They  may  be  confined  to  one  ear  or  heard  in  both  :  the  voice 
may  be  that  of  a  friend  or  a  stranger,  male  or  female.  The 
soimd  may  appear  to  come  from  above  or  below,  or  even  from 
the  abdomen.  The  conversation  may  be  of  a  pleasant  or 
unpleasant  character  ;  the  words  may  be  persuasive  or  com- 
manding. Another  point  of  interest  regarding  auditory  hallu- 
cinations is  that  they  are  very  frequent  in  deaf  persons. 

Visual  Hallucinations. — Visual  hallucinations  are  very  com- 
monly met  with  in  many  types  of  insanity,  and  more  especially  in 
those  forms  of  mental  disorder  due  to  fatigue  or  to  drugs  such 
as  alcohol  and  cocaine,  and  in  delirious  states  they  vary  greatly 
in  character  ;  they  may  appear  merely  as  lights  or  shadows, 
or  may  be  more  complicated.  Faces  of  friends  or  foes,  faces 
with  horrible  and  distorted  expressions,  angels  or  devils,  animals 
or  vermin,  spectres  or  ghosts,  are  some  of  the  forms  that  these 
hallucinations  may  assume.  The  objects  seen  may  be  fiat  or 
may  stand  out  in  rehef.  In  the  matter  of  colouring  the  most 
common  type  is  black  or  white  ;  a  certain  percentage  are  blue, 
but  bright  colouring  is  rare.  They  may  be  stationary  or  floating 
about  in  the  air  ;  others  keep  moving  from  left  to  right,  or 
right  to  left,  according  to  whether  the  patient  is  a  right  or 
left-handed  individual.  Homonymous  hemiopic  hallucinations 
have  also  been  observed,  and  are  usually  but  not  invariably 
associated  with  a  corresponding  hemianopsia.  Hallucination 
of  vision  may  occur  in  the  blind. 

Gustatory  Hallucinations. — Gustatory  hallucinations  are  also 
common  and  of  importance,  as  they  frequently  lead  to 
refusal  of  food  by  patients  on  the  ground  that  the  food  has 
been   tampered   with.     In   these   hallucinations   the   taste   is 


GENERAL  SYMPTOMATOLOGY  55 

usually  described  as  '  bitter,'  or  it  may  be  some  compound 
taste  such  as  that  of  filth.  Hyslop  in  his  '  Mental  Physiology  ' 
briefly  sums  up  the  various  perversions  of  taste  as  follows  : 

'  (1)  Hypergeusia,  exaltation  of  the  sense  of  taste,  i.e. 
there  is  a  morbid  exaggeration  of  all  gustatory  sensations,  as 
seen  in  some  forms  of  neurasthenia,  extreme  nervousness,  and 
sometimes  even  in  conditions  of  mania  and  melancholia. 

'  (2)  Hypogeusia,  diminution  of  the  sense  of  taste ;  at 
times  met  with  in  acute  maniacal  or  melancholic  states,  in 
cases  of  stupor  with  general  blunting  of  the  sensibility. 

'  (3)  Ageusia,  absence  of  sense  of  taste,  met  with  in  some 
organic  conditions. 

*  (4)  Parageusia,  perversion  of  the  sense  of  taste,  as  seen 
-in  nearly  every  form  of  insanity.  Gustatory  hallucinations  are 
frequently  associated  with  perversion  of  smell.' 

Olfactory  Hallucinations. — Olfactory  hallucinations  are  of 
varied  kinds.  They  may  be  sweet  and  pleasant,  but  are 
more  commonly  offensive.  Savage  believes  that  perversions 
of  smell  are  closely  connected  with  uterine  and  ovarian 
disorders. 

Tactual  Hallucinations. — Hallucinations  of  common  cuta- 
neous sensibility  are  frequently  electrical  in  character.  Sen- 
sations that  insects  are  crawling  over  the  skin,  feelings  of  dirt, 
dryness  or  moisture  are  also  met  with.  The  so-called  epigastric 
sensation  is  very  common,  the  feeling  being  described  in 
varied  ways  as  a  fullness,  sinking  or  actual  pain.  Among  these 
perversions  of  tactual  sensation  must  be  mentioned  those 
which  lead  a  patient  to  affirm  that  his  sexual  organs  are  being 
tampered  with  ;  these  are  especially  common  in  some  cases 
of  paranoia. 

Psycho-motor  Hallucinations  is  the  term  given  to  the  sense 
of  movement  when  no  actual  movement  is  taking  place.  Hal- 
lucinations of  this  type  may  occur  in  any  part  of  the  body ; 
one  patient  may  feel  his  brain  swinging  to  and  fro,  another 
may  believe  that  he  has  struck  some  one  near  him,  whilst 
another  may  feel  that  he  is  saying  blasphemous  words. 

Examples  of  these  various  types  of  hallucinations  might 
be  given  in  infinite  variety  if  space  permitted,  but  no  good 
purpose  would  result. 


56  PSYCHOLOGICAL  MEDICINE 

The  physician  must  always  consider  what  effect  any  halUi- 
cinations  may  have  on  a  given  case.  In  the  first  place,  it  is 
not  alwaj's  easy  to  diagnose  the  presence  of  hallucinations 
in  an  individual  who  is  suspicious  and  uncommunicative. 
Watch  the  patient's  movements  and  general  conduct,  for  in 
this  way  much  may  be  learned.  Commanding  auditory 
hallucinations  are  dangerous,  for  '  voices  '  of  this  kind  may 
lead  a  patient  to  commit  acts  of  violence  against  himself 
or  others.  Belief  that  food  is  being  poisoned  results  in  refusal 
of  food,  except  in  those  cases  where  the  patient  is  able  to 
cook  all  his  own  meals.  To  sum  up  :  hallucinations  of  the 
various  senses  account  for  many  of  the  vagaries  of  conduct 
in  the  insane.  Some  persons  are  greatly  influenced  by  their 
presence,  and  may  act  upon  their  promptings.  Hallucinations 
frequently  confirm  pre-existing  delusions.  The  patient,  at 
first  merely  suspicious  that  others  are  against  him,  is  at  length 
confirmed  in  this  belief  by  hearing  the  disparaging  remarks, 
or  by  tasting  the  poison  which  he  believes  to  have  been  pre- 
pared for  him.  For  this  reason  persistent  hallucinations  are 
apt  to  indicate  chronic  mental  disorder,  as  the  patient  bases 
his  life  and  actions  on  these  altered  conditions,  not  realising 
that  he  is  being  deceived  by  his  own  senses. 

To  explain  the  development  of  hallucinations  is  by  no  means 
easy.  Some  are  no  doubt  peripheral  in  their  origin,  while 
others  appear  to  be  central.  External  ear  disease  may  pro- 
duce auditory  hallucinations  in  the  same  way  that  disorders 
of  the  eye  or  of  the  skin  surfaces  may  give  rise  to  other  sensory 
perversions. 

Other  common  causes  are  peripheral  neuritis  and  distm'b- 
ances  of  the  circulatory  system.  Hallucinations  may  be 
fantastic  in  their  arrangement,  but  are  not  absolutely  new 
creations  :  the  devil  seen  by  the  melancholiac  is  the  goblin  of 
the  fairy  tale  or  the  Mephistopheles  of  '  Faust.'  They  are  all 
memory-types,  and  more  or  less  follow  the  laws  of  association. 
Auditory  and  visual  illusions  or  hallucinations  may  be  set  up 
by  any  form  of  stimulus  acting  on  nerve-endings  and  thence 
upon  the  centres  of  sight  and  hearing  in  the  brain.  On  the 
other  hand,  can  the  centre  act  independently  of  any  external 
stimulus  ?  Can  it  in  a  sudden  and  unprovoked  way  pass  into 
a  state  of  commotion,  and  cause  the  reproduction  of  memory- 


GENERAL  SYMPTOMATOLOGY  57 

ideas  wliich  may  have  been  latent  for  years  ?  This  question 
must  be  answered  in  the  affirmative,  as  there  seems  increasing 
evidence  to  prove  that  such  is  the  case.  After  all,  why  should 
it  not  be  possible  for  the  centres  to  be  irritated  and  set  in  action 
by  the  very  blood  in  which  they  are  bathed,  especially  when 
the  blood  contains  toxins  or  other  irritants,  as  in  all  likehhood 
is  the  case  in  many  forms  of  mental  disease  ?  The  effect  of 
drugs  in  the  production  of  hallucinations  is  variable,  some 
drugs  acting  directly  on  the  centres,  others  on  the  peripheral 
ends  of  nerves. 

Hughlrngs  Jackson  has  ingeniously  suggested  that  illa- 
sions  and  hallucinations  may  arise  in  the  following  way. 
"When  any  area  of  the  brain  is  damaged,  or  becomes  func- 
tionally deranged,  there  will  in  consequence  be  two  sets  of 
symptoms  in  evidence — ^the  negative  symptoms,  due  to  the 
non-activity  of  the  damaged  portion  of  the  brain  ;  and  the 
positive  symptoms,  due  to  the  over-activity  of  the  lower 
centres,  which  are  now  no  longer  controlled  by  the  higher 
centres,  which  have  become  disorganised.  Hughhngs  Jackson 
suggests  that  illusions  and  hallucinations  may  result  from 
the  over-activity  of  the  lower  centres.  Stoddarfc  ^  considers 
that  there  is  practically  no  psychical  difference  between 
perception,  ideation,  illusions,  and  hallucinations,  and  there- 
fore the  differences  must  be  sought  among  the  physical  bases 
of  these  processes.  He  states  that  '  the  most  obvious  difference 
is  that,  while  in  perceptions  and  illusions  there  is  a  stimulus 
to  the  peripheral  end-organs,  in  ideation  and  hallucinations 
there  is  no  such  stimulus  ;  in  visual  perceptions  and  illusions 
the  stimulus  to  the  angular  gyrus  arrives  by  way  of  the  optic 
radiations,  occipital  lobe,  and  occipito-angular  association- 
fibres  ;  but  in  the  case  of  ideation  and  hallucination,  the 
stimulus  reaches  it  by  way  of  other  association-fibres  than  the 
occipito-angular  bundle.  Confirmation  of  this  proposition  is 
afforded  by  the  existence  of  visual  hallucinations  in  the  blind, 
auditory  hallucinations  in  the  deaf,'  etc.  Now,  when  a  patient 
has  an  hallucination  of  vision,  there  is  a  negative  as  well  as 
a  positive  side  to  the  process.  The  positive  side  is  that  he 
sees  the  hallucination  image,  the  negative  is  that  he  does  not 

^  '  The  Psychology  of  Hallucinations,'  Journal  of  Menhd  Science,  October, 
1904. 


58  PSYCHOLOGICAL  MEDICINE 

see  objects  in  the  neighbourhood  of  the  image.  Stoddart 
considers  that  hallucination  depends  upon  two  factors — - 
diminution  of  sensation,  and  disturbance  of  association ; 
and  further  that  these  factors  vary  inversely  in  the  several 
conditions  in  which  hallucination  occurs.  For  example, 
with  delirium  of  fever  and  in  the  excited  stage  of  acute  mania 
there  is  little  diminution  of  sensation  and  great  disturb- 
ance of  association  ;  in  cases  of  nitrous  oxide  or  chloroform 
inhalation  there  is  little  disturbance  of  association  and  great 
diminution  of  sensation. 

The  '  reflex  hallucinations  of  Kahlhaum '  are  supposed  to 
arise  in  another  way.  An  ordinary  sensory  stimulus  acting 
on  a  hypersensitive  sensory  centre  may  set  up  reflex  hallu- 
cinations. As  already  stated,  a  deaf  or  blind  person  may 
suffer  from  hallucinations  of  the  senses  in  which  he  is  defec- 
tive ;  on  the  other  hand,  the  congenitally  deaf  never  have 
auditory  hallucinations,  neither  do  the  congenitally  blind 
have  visual  hallucinations.  This  clearly  shows  that,  whether 
the  excitation  be  central  or  peripheral  in  origin,  hallucina- 
tions are  the  reproduction  of  former  memory-images. 

Delusions. — A  delusion  is  a  false  belief.  But  here  we  are 
met  with  a  difficulty  at  the  very  outset.  Who  is  to  deter- 
mine what  is  a  delusion  ?  We  are  born  into  a  community, 
and  have  to  conform  to  its  social  laws  and  dictates,  and  even 
if  we  disagree  with  the  rules  which  it  prescribes,  we  must 
not  actively  disobey  them.  Society,  to  use  the  word  in 
its  broadest  sense,  permits  a  certain  amount  of  latitude  in 
obedience  to  its  regulations  ;  but,  in  the  main,  the  views  of 
the  majority  are  paramount.  Now,  beliefs  are  largely  the  tradi- 
tions and  ideas  which  have  been  handed  down  by  parents  and 
teachers  ;  they  are  ready-made  and  must  be  accepted.  The 
normal  evolution  that  is  ever  taking  place  in  all  things  permits 
the  adaptation  of  the  older  ideas  to  the  latter-day  demands. 
So,  in  considering  the  question  of  delusions,  we  must  bear  in 
mind  certain  ascertained  or  ascertainable  facts.  Among  the 
most  important  of  these  are  the  traditions  of  the  country  in 
which  we  live.  For  example,  if  a  person  were  to  adopt  some 
of  the  habits  of  life  in  vogue  in  distant  lands,  and  were  to 
conduct  himself  in  Kegent  Street  as  Kaffirs  or  Basutos  do  in 
their  country,  he  would  unhesitatingly  be  pronounced  insane. 


GENERAL  SYMPTOMATOLOGY  '59 

The  degree  of  education  and  the  social  status  of  a  person, 
whose  conduct  is  under  consideration,  are  also  important 
facts,  for  habits  which  would  be  regarded  as  decidedly  eccen- 
tric in  educated  members  of  the  upper  classes,  might  pass 
unremarked  in  the  lower  grades  of  society. 

It  is  obvious  that  any  one  may  have  a  false  belief,  but  the 
sane  man  corrects  his  ideas  and  conclusions  by  his  reasoning 
power,  he  applies  his  past  experience,  and  listens  to  the  argu- 
ments of  others.  In  this  way  he  differs  from  the  insane  man, 
whom  no  force  of  reasoning  will  convince,  but  who  prefers  to  be 
guided  by  his  own  feelings  and  sensations.  Defendorf  i  writes 
on  this  subject  as  follows :  '  Delusions  are  iiiaccessible  to  argu- 
ment, because  they  do  not  originate  in  experience  ;  experience 
.therefore  is  unable  to  correct  them  as  long  as  they  remain 
delusions.  Only  in  convalescence,  when  they  become  a  mere 
memory  of  delusions,  can  they  ,  be  recognised  as  false.  At 
the  height  of  the  disease  they  are  as  firmly  established  as 
reason  herself.  So  long  as  the  morbid  conditions  which  give 
rise  to  them  persist,  the  delusions  are  unchanged.  If  they 
are  relinquished  or  modified,  the  change  is  not  due  to  argu- 
ment, but  to  a  change  in  the  morbid  condition.  Our  arguments 
may  drive  the  patient  to  admit  non-essential  points,  but  the 
delusion  serenely  reasserts  itself  notwithstanding  the  most 
evident  self-contradiction.  Even  when  the  external  object  of 
reference  or  support  is  destroyed,  a  new  one  is  quickly  found. 
The  delusion  needs  no  other  support  than  the  absolute  con- 
viction of  the  deluded.'  '  I  feel  that  I  am  lost  for  ever  ! '  is  the 
cry  of  the  clergyman,  notwithstanding  that  he  has  taught  the 
way  of  salvation  to  his  parishioners  for  years.  Altered  feel- 
ings and  sensations  outweigh  all  arguments  and  reasoning. 
Strong  emotional  states  tend  to  the  production  of  delusions. 
Some  writers  believe  that  the  '  clouding  of  consciousness  ' 
is  an  important  factor  in  their  development.  This  may  be  so, 
but  perhaps  it  would  be  more  accurate  to  say  that  in  some 
mental  states  there  is  loss  of  power  of  com'parison.  Memory 
and  attention  may  be  defective,  and  thus  the  ideas  of  the 
moment  may  be  misleading.  Especially  is  this  the  case  when 
ideas  are  vivid  and  impressive.  Probably  some  of  the  delu; 
sions  observed  in  general  paralysis  and  certain  delirious  states 
^  Clinical  Psychiatry. 


60  PSYCHOLOGICAL  MEDICINE 

originate  in  this  way.  A  general  classification  of  delusions 
may  be  helpful  to  the  student,  and  no  better  can  be  given  than 
that  drawn  up  by  Mercier.i 

I.  Disorders  of  the  Consciousness  of  Self. 

A.  Disorders  of  self-conscious  feeling. 

B.  Disorders  of  thought. 

A.  There  are  three  subdivisions  of  the  disorders  of  feeling 
of  self. 

(a)  Elevation  of  self-consciousness.  Exaggerated  feelings 
of  well-being  and  vigour.     Buoyancy  and  general  exaltation. 

{h)  De'pression  of  self-consciousness.     Depression  and  misery. 

(c)  Alteration  of  consciousness.  This  is  a  condition  separate 
from  either  elevation  or  depression,  in  which  the  feeling  of  self 
is  altered. 

B.  Delusions  of  the  thought,  as  distinguished  from  the  feeling, 
of  self.  These  may  be  general  or  local.  They  may  include 
the  knowledge  of  the  body  as  a  whole,  or  the  knowledge  of  parts 
only. 

1.  Delusions  of  knowledge  of  whole  of  self. 

2.  Delusions  of  knowledge  of  parts  of  self. 

1.  (a)  In  some  cases  the  old  self  is  found  to  be  replaced 
by  a  new  ;  a  man  loses  his  own  identity,  and  believes  that  he 
is  something  else. 

(b)  In  others  the  old  self  and  the  new  self  alternate.  A 
person  passes  through  alternating  phases  of  existence  of 
days'  or  weeks'  duration. 

(c)  Further,  in  other  cases  the  old  self  and  the  new  self 
coexist,  and  the  patient  believes  himself  to  be  two  persons 
at  once.  This  is  met  with  in  those  persons  who  suffer  from 
a  double  hallucinatory  condition,  e.g.  where  the  auditory 
hallucinations  of  the  right  side  quarrel  with  those  of  the  left. 

2.  (a)  Partial  disorder  of  the  knowledge  of  the  whole  self 
is  seen  in  those  persons  who,  while  preserving  a  knowledge  of 
their  own  identity,  believe  that  they  are  changed  in  some  im- 
portant particular,  as,  for  instance,  in  sex,  or  that  they  are 
composed  of  glass  or  iron. 

^  Tuke's  Dictionary  of  Psychological  Medicine, 


GENERAL  SYMPTOMATOLOGY  61 

{h)  Cases  of  disorder  of  the  knowledge  of  parts  of  self  are 
also  common  ;  for  example,  a  man  may  believe  that  his  head 
is  open,  and  that  his  brains  have  been  removed,  and  replaced 
by  some  other  material. 

11.  Disorders  of  the  Consciousness  of  the  Relation  of  Self 
to  Surroundings. 

This  is  further  divided  into — 
(a)  Delusions  of  the  relation  of  self  to  surrou7idings. — These 
are  of  two  kinds,  delusions  either  of  increased  welfare  or 
diminished  welfare.  Under  the  first  head  fall  delusions 
of  power,  of  wealth,  of  influence,  including  the  delusions  of 
those  who  think  themselves  millionaires,  kings,  etc.  Under 
the  second  head  fall  self-accusatory  delusions. 

{h)  Delusions  of  the  relation  of  surroundings  to  self. — These 
are  similarly  divisible  into  delusions  of  beneficent  relation 
and  delusions  of  inimical  relation.  The  former  include  the 
delusions  of  those  who  believe  honours  or  commands  are 
conferred  upon  them ;  the  latter,  an  exceedingly  common 
and  in  practice  a  most  important  group,  include  the  delusions 
of  those  who  believe  themselves  to  be  the  victims  of  per- 
secution. Substantially  all  classes  of  delusions  are  included 
in  the  above  classification. 

Delusions  are  found  to  be  present  in  nearly  every  form  of 
mental  disorder.  In  some  conditions  they  seem  to  be  the 
outcome  of  the  insanity  ;  in  others  they  seem  to  form  its  very 
basis.  For  example,  some  delusions  are  merely  the  explana- 
tion offered  for  altered  feelings  ;  these  are  common  in  the  case 
of  emotional  insanities  such  as  mania  and  melancholia.  The 
patient  feels  miserable,  and,  as  Savage  tersely  puts  it,  '  explains 
his  condition  from  the  standpoint  of  mind,  body,  or  estate.' 
These  delusions  may  be  fleeting  and  transient,  or  may  become 
more  organised.  On  the  other  hand,  in  the  ideational  forms 
of  mental  disorder,  delusions  are  slow  in  development,  and 
may  for  years  pass  almost  unnoticed.  Delusions  of  grandeur 
and  pride  may  spring  from  a  haughty  nature  ;  jealousy  and 
suspicion  may  be  the  forerunners  of  definite  delusions  of 
persecution. 

Delusions  are  the  outward  and  visible  sign  of  an  altered 
mental  state.    Lawyers  and  jurymen  feel  that  they  have  some 


62  PSYCHOLOGICAL  MEDICmE 

tangible  proof  of  mental  disorder  when  a  definite  delusion 
can  be  instanced  ;  but  to  the  physician  its  presence  is  of  httle 
importance,  except  as  lending  some  assistance  in  indicating 
the  line  of  treatment.  A  question  of  far  greater  importance 
is,  *  Why  is  the  delusion  there  ?  '  Delusions  are  merely  symp- 
toms, and  the  physician  must  endeavour  to  discover  the 
reason  for  their  presence.  This  sounds  Hke  emphasising  the 
obAdous,  but  it  is  the  obvious  that  often  is  overlooked.  Many 
a  physician  thinks  that  he  has  discovered  everything  about 
a  patient  when  he  has  dejQnitely  detected  a  delusion.  He  has 
not :  the  delusion  may  be  here  to-day  and  gone  to-morrow, 
while  the  mental  disorder  may  persist.  In  some  cases  delu- 
sions are  ever  changing,  and  are  merely  the  audible  reflection 
of  a  passing  thought.  The  term  '  fixed  delusion  '  has  been 
appHed  to  that  class  of  delusion  which  is  more  or  less  per- 
manent, and  which  is  a  dominating  factor  in  the  hfe  of  the 
patient.  There  are  also  so-called  '  fixed  ideas  '  and  '  obses- 
sions,' but  these  will  be  dealt  with  elsewhere.  The  presence 
of  delusions  does  not  necessarity  argue  mental  weakness,  and 
clinically  it  will  be  found  that  many  who  suffer  in  this  way 
are  perfectly  capable  of  transacting  business,  provided  their 
delusions  are  not  such  as  to  obscure  judgment  in  matters  to 
which  then-  business  relates.  Delusional  states  are  frequently 
associated  mth  hallucinations,  and  may  be  secondary  to  the 
sensory  disturbances.  In  alcohohc  insanities  and  those  forms 
of  mental  disorder  due  to  poisons,  the  delusions  are,  as  a 
rule,  the  result  of  haUucinations,  while  in  other  types  of  in- 
sanity the  hallucinations  are  usually  secondary  to  the  delusion. 
Delusions  occm-  both  in  the  sane  and  the  insane.  Taken 
by  themselves,  they  do  not  necessarily  indicate  insanity,  but 
their  presence  is  strongly  indicative  of  mental  disorder  when 
they  are  found  in  conjunction  with  other  evidence,  such 
as  failure  of  general  conduct  and  neglect  to  conform  to  the 
ordinary  rules  of  life  and  society. 

Disorders  of  Attention. — The  disorders  of    attention  are  of 
two  kinds  : 

(1)  Hyperattention  ;     (2)  Inattention. 

The  normal  mind  ought   to   be   polyideational   and   should 
be  capable  of   concentration  on  any  subject  which  demands 


GENERAL  SYJIPTOMATOLOGY  63 

its  attention  ;  but  when  there  is  a  reduction  from  general 
intellectual  activity  to  concentration  upon  one  idea,  we  get 
hyperattention.  Fixed  ideas  are  found  in  several  conditions  ; 
they  may  be  due  to  a  pm'ely  intellectual  change,  or  may  be 
accompanied  by  emotion.  The  most  common  variety  of  fixed 
ideas  is  seen  in  oft-recurring  imperative  ideas,  usually  spoken 
of  as  obsessions.  Inattention  is  due  either  to  absence  of 
power  of  reinforcing  an  idea,  or  to  the  impossibility  of  inhibiting 
accidental  external  influences  w^hich  have  no  relation  to  the 
needs  of  the  moment.  Inattention  may  be  due  to  failure  of 
evolution — the  power  of  concentration  of  mental  faculties  on 
a  subject  never  having  been  acquired — or  it  may  be  due  to  dis- 
solution. Failure  of  attention  is  seen  in  fatigue,  in  mental 
states  after  serious  physical  illness,  in  intoxication,  and  in 
many  forms  of  mental  disorder.  Dream  consciousness  is  an 
example  of  an  extreme  degree  of  inattention  ;  and  to  this  is 
largely  due  the  fantastic  arrangement  of  ideas  in  dreams, 
in  that  there  is  no  governing  idea  upon  which  attention  is 
centred,  but  every  idea  has  an  equal  chance.  The  im- 
portance of  inattention  as  a  symptoln  is  very  great.  It 
usually  occurs  in  every  form  of  mental  disease,  and  accounts 
for  much  of  the  inaction  exhibited  by  the  insane.  A  person 
who  is  preoccupied  in  considering  his  o^tl  thoughts  and  feelings 
cannot  apply  himself  to  the  wants  of  others  ;  it  is  largely  for 
this  reason  that  the  insane  keep  so  much  to  themselves.  As 
mental  improvement  takes  place  they  become  more  altruistic, 
and  more  attentive  to  the  requirements  of  their  fellow-patients. 
Attention  is  of  late  development,  and  therefore  goes  early  ;  and 
inattention,  or  easy  distractabihty,  is  frequently  one  of  the 
earhest  symptoms  which  are  noted  in  the  onset  of  mental  disease. 

Inattention  also  plays  an  important  part  in  the  question 
of  memory  ;  perceptions  and  ideas  to  which  attention  has 
been  given  are  remembered,  whilst  an  inattentive  individual 
wiU  often  seem  to  have  a  bad  memory. 

Subject-Consciousness  and  Object- Consciousness. — Closely  con- 
nected with  hyperattention  and  inattention  are  the  rise 
of  subject-consciousness  and  the  fall  of  object-conscious- 
ness, which  are  such  prominent  symptoms  in  mental  disease. 
The  meaning  of  these  terms  has  been  already  described 
in   a   former   chapter.    As  Bevan  Lewis  shows,  the  rise  in 


64  PSYCHOLOGICAL  MEDICINE 

subject-consciousness  is  the  'positive  aspect  of  the  patient's 
mental  state,  and  is  that  which  attracts  the  most  notice. 
This  is  very  markedly  the  case  in  melancholia,  where 
every  thought  and  action  of  the  patient  is  colom'ed  by  his 
miserable  feelings.  Similarly  the  decline  in  object-conscious- 
ness represents  the  negative  aspect.  '  The  decUne  in  object- 
consciousness  which  occurs  in  states  of  pathological  depression 
presents  us  with  the  following  features  :  (a)  enfeebled  re- 
presentativeness ;  (&)  a  lessened  seriality  of  thought  (weakened 
attention)  ;  (c)  diminution  or  failure  in  the  muscular  element 
of  thought.'  1 

Muscular  Element  of  Thought. — Bevan  Lewis  points  out 
that,  in  addition  to  the  five  special  senses,  there  is  a  sixth 
sense,  the  muscular  sense,  which  tells  us  of  size,  position,  and 
form.  He  goes  on  to  show  that  the  full  perception  of  things 
about  us  is  largely  due  to  the  proper  and  vigorous  working 
of  this  muscular  sense.  Now,  if  this  sense  undergoes  any 
diminution,  correspondingly  the  space  attributes  of  the 
body  become  less  vividly  conceived.  Proper  vision  is  largely 
dependent  upon  the"  muscular  mechanism  involved  in  our 
perception  of  objects.  Bevan  Lewis  also  observes  that  *  we 
must  distinguish  between  that  portion  of  the  muscular  element 
which  enters  into  our  higher  intellectual  concepts,  and  that 
grosser  factor  of  the  larger  musculatm'e  of  the  limbs,  etc., 
which  subserves  the  pm^pose  of  locomotion  and  coarse  move- 
ments. The  sense  of  muscular  contractions  which  forms  the 
basis  of  the  primordial  ideas  of  form,  size,  and  position, 
lapses  eventually  in  consciousness  as  a  pure  sense  of  muscular 
contraction.  With  the  larger  musculature  this  is  not  so  ;  it 
is  essential  that  the  movements  of  the  limbs,  their  contraction 
and  tension,  should  be  exquisitely  registered  centrally,  as 
thereby  alone  can  we  gain  an  idea  of  their  position  in  space 
apart  from  the  sense  of  sight,  and  appreciate  the  relative 
weight  of  objects  and  the  resistance  offered  by  them.  The 
unrestrained  action  of  these  muscles  signalises  to  our  minds 
the  absence  of  external  resistance,  and  the  rise  in  the  muscular 
sense  which  accompanies  any  resistance  opposed  is  the  direct 
measure  of  such  resistance.  Similarly  with  the  "  Muscularity 
of  Thought,"  which  in  the  normal  state  is  of  free  and  easy 
^  A  Text-book  of  Mental  Diseases.     Bevan  Lewis. 


GENERAL  SYMPTOMATOLOGY  65 

play,  the  rise  into  consciousness  of  its  primordial  muscular 
element  means  effort,  and  at  once  suggests  to  the  mind  the 
same  notion  of  resistance  in  the  environment.''  Now,  with 
failure  of  object-consciousness  there  is  a  sense  of  resistance  in 
the  environment ;  thus  the  melanchohac  does  not  gi'asp  his 
relation  with  the  external  world.  Again,  if  a  man  fails  to  do  a 
thing  on  account  of  loss  of  object-consciousness,  he  is  annoyed, 
and  there  is  a  fm'ther  rise  of  subject-consciousness  ;  his  idea  of 
self  alters,  and  delusions  result — ^usually  by  way  of  explain- 
ing the  altered  conditions.  Another  example  of  the  effect  of 
muscular  contraction  on  thought  and  feeling  can  be  demon- 
strated by  the  voluntary  relaxation  of  the  facial  and  limb 
muscles  when  the  mind  is  in  a  state  of  tension  or  irritability. 
The  reader  can  test  this  for  himself  and  he  will  notice  how 
rapidly  this  tension  is  replaced  .by  a  sense  of  repose. 

Disorders  of  the  Association  of  Ideas. — The  power  of 
associating  ideas  may  be  disordered  in  two  ways  :  (1)  The 
flow  of  ideas  may  be  retarded  ;  this  is  to  be  observed  in  states 
of  mental  enfeeblement,  in  exhaustion  states,  in  melancholia, 
and  in  organic  disease  where  there  is  destruction  of  the  cortical 
neurons,  in  disease  such  as  general  paralysis,  and  in  local 
lesions  of  the  brain.  (2)  The  flow  of  ideas  may  be  accelerated  in 
delii'ious  and  maniacal  states,  and  is  often  spoken  of  as  the 
'  flight  of  ideas.' 

Disorders  of  Memory. — Disorders  of  memory  fall  into  three 
main  classes  :  (1)  Amnesic  States,  or  loss  of  memory  ;  (2) 
Hypermnesic  States,  where  there  is  exaltation  of  memory  ;  and 
(3)  Paramnesic  States,  or  illusions  of  memory. 

1.  Failure  of  memory  follows  the  ordinary  law  of  disso- 
lution of  the  nervous  system — ^that  is,  that  the  latest  acquired 
and  consequently  the  least  organised  attributes  disappear 
first,  the  failm'e  being  in  inverse  order  to  the  order  of  acqui- 
sition. The  patient  is  no  longer  able  to  store  fresh  impres- 
sions, and  the  events  of  long  ago  reappear  with  the  vividness 
of  an  event  of  yesterday.  How  often  is  it  said,  '  Oh,  his 
memory  is  excellent  ;  he  remembers  events  which  happened 
years  and  years  ago  which  I  have  long  forgotten  !  '  But 
such  a  memory  is  of  little  use  in  comparison  with  the  memory 
which  is  retentive  of  events  of  recent  occurrence,  and  is  indeed 
consistent   with   and   sometimes   symptomatic   of  impending 

5 


66  PSYCHOLOGICAL  MEDICINE 

failure.     Eibot  in  his  '  Diseases  of  Memory  '  gives  the  follow- 
ing classification  of  Amnesic  states  : 

1.  Congenital  defects. 

2.  Conditions  of  tem'porary  loss  : 

(a)  In  epilepsy. 

(&)  Following  injury  or  shock. 

(c)  In  acute  mental  disorders. 

3.  Conditions  of  'periodic  loss  : 

{a)  In  states  of  double  consciousness. 
{h)  In  somnambulistic  states. 

4.  Conditions  of  frogressive  loss  : 

(a)  In  general  paralysis  of  the  insane. 
(&)  Associated  with  various  brain  lesions, 
(c)  In  senile  dementia. 

5.  Conditions  of  'partial  loss   (as   seen  in  loss  of  memory 

for  names,  aphasia  of  all  kinds,  music,  etc.). 

Defects  of  memory  may  be  due  to  failure  of  evolution  or 
to  a  temporary  or  progressive  dissolution.  A  true  amnesia 
is  always  a  factor  of  great  importance  in  considering  the 
prognosis  of  a  case  of  mental  disorder.  As  a  general  working 
rule,  when  the  memory  is  found  to  be  bad  or  progressively 
failing,  the  outlook  for  recovery  is  not  good.  The  memory 
is  not  very  defective  in  acute  functional  forms  of  mental 
disorder  ;  and,  if  it  is  found  to  be  lost  or  progressively  failing, 
it  generally  indicates  some  organic  change.  Care  must 
always  be  taken  in  testing  the  memory,  as  it  may  appear  to 
be  defective  when  the  condition  is  really  only  due  to  lack  of 
observation  ;  this  is  often  the  case  in  melancholia.  Further, 
memory  must  be  tested  for  both  recent  and  remote  events, 
and  it  is  the  failure  of  memory  for  recent  events  that  is  of  most 
diagnostic  value.  Loss  of  memory  is  often  most  marked  in 
persons  suffering  from  arteriosclerotic  and  senile  changes  in 
the  brain.  It  is  frequently  a  matter  of  great  difficulty  to 
decide  whether  a  person  with  loss  of  memory,  and  with  no 
other  marked  mental  disturbances,  should  be  placed  under 
care.  It  is  largely  a  question  of  the  financial  position  of 
the   patient.     If   his   circumstances    are   sufficiently   affluent 


GENERAL  SYMPTOMATOLOGY  67 

to  insure  his  receiving  careful  attendance  at  his  home,  it  is 
rarely  necessary  to  send  him  away.  If,  however,  his  means 
do  not  enable  such  provision  to  be  made,  it  may  be  expedient 
to  place  him  in  safe  keeping.  Loss  of  memory  may  seriously 
affect  conduct.  An  amnesic  person  may  seriously  contravene 
moral  and  social  codes.  He  may  relieve  his  bladder  in  some 
public  place  in  entire  ignorance  that  he  is  offending,  or  he 
may  wander  away  from  home  and  be  totally  unable  to  account 
for  himself.  Frequently,  loss  of  memory  leads  to  inability 
to  provide  means  of  livelihood  either  for  the  patient  himself 
or  his  dependants. 

There  is  little  doubt  that  patients  afflicted  with  loss  of 
memory  are  in  many  cases  happier  and  better  cared  for  in 
asylums  than  they  can  be  elsewhere.  There  is  certainly 
ah  increasing  tendency  to  send  senile  amnesiacs  of  the  pauper 
class  into  asylums  ;  and  this,  to  a  certain  extent,  accounts 
for  the  great  increase  in  the  insane  population  in  these  in- 
stitutions. Though  this  is  well  for  the  patients,  it  is  bad 
for  the  ratepayers.  It  would  be  a  wise  economy  if  suitable 
infirmaries  could  be  established  for  cases  of  this  type,  as  it 
would  relieve  the  costly  machinery  of  the  regular  asylum. 
As  already  observed,  if  there  is  marked  loss  of  memory,  the 
prognosis  is  usually  bad  ;  but  there  are  notable  exceptions 
to  this  rule.  In  certain  cases  of  alcoholic  insanity,  and  in 
some  forms  of  stupor  and  exhaustion  states,  the  memory  is 
bad,  and  yet  there  is  a  fair  chance  of  recovery.  Loss  of 
memory  is  most  marked  in  the  following  forms  of  mental 
disorder  :  (1)  general  paralysis  of  the  insane  ;  (2)  chronic 
alcoholism ;  (3)  progressive  mental  disorder ;  (4)  stupor 
and  nerve  exhaustion  states ;  (5)  senility ;  (6)  organic 
dementia. 

2.  Hypermnesic  States. — These  may  be  : 

(1)  Congenital. 

(2)  Temporary. 

(3)  Periodic. 

(4)  Partial. 

This  condition  of  exaltation  of  memory  is  seen  not  in^ 
frequently  in  acute  fevers,  and  notably  with  poisoning  by 
drugs — such    as    hashish.     It   is    a    symptom   which   is    not 


68  PSYCHOLOGICAL  MEDICINE 

uncommonly  present  in  some  cases  of  excitement.  Partial 
hypermnesia  is  sometimes  fomid  in  imbecile  and  weak- 
minded  persons.  Some  such  patients  may  remember  the 
names  of  all  individuals  whom  they  meet,  even  casually,  others 
remember  dates  in  an  extraordinary  way. 

3.  Paramnesic  States,  or  illusions  of  memory.  Incidents 
which  never  occurred  seem  to  be  famihar,  in  fact  so  familiar 
as  to  have  been  part  of  past  experience.  As  already  stated 
in  a  former  chapter,  an  essential  factor  in  a  memory-idea  is 
the  feeling-tone  of  famiharity  which  accompanies  that  idea. 
Therefore,  should  this  feehng-tone  arise  with  any  sensation 
or  perception,  the  result  will  be  similar  to  that  of  ordinary 
recognition  or  memory.  A  common  instance  of  paramnesia 
in  a  sane  person  is  when  he  has  told  a  story  of  some  event  a 
number  of  times,  and  each  time  tells  it  as  if  it  happened  to 
himself,  until  finally  he  becomes  firmly  convinced  that  he 
was  really  present  when  the  incident  took  place.  The 
feehng-tone  of  famiharity  is  supplied  by  the  description  he 
has  given  on  former  occasions.  Paramnesia  is  common  in 
chronic  alcohohc  disorders,  especially  in  the  variety  known 
as  Korsakow's  disease,  a  polyneuritic  psychosis. 

Disturbances  of  the  Emotions. — Disturbances  of  the  emotions 
are  very  common  in  the  insane,  and,  in  certain  instances, 
may  form  the  chief  symptom  of  the  mental  disorder.  In  the 
early  stages  of  general  paralysis  of  the  insane,  and  in  several 
varieties  of  insanity,  the  emotions  may  be  in  an  exaggerated 
state  of  irritability.  Small  annoyances  may  cause  outbursts 
of  passion  and  temper.  At  one  moment  the  patient  may  be 
laughing  and  at  the  next  weeping.  The  emotions  seem  to  be 
poised  in  a  condition  of  unstable  equiHbrium,  and  are  ever 
ready  to  respond  violently  to  shght  stimuli.  This  condition 
is  very  commonly  seen  in  states  of  excitement  apart  from 
organic  disease.  The  alcohohc  is  at  times  very  emotional ;  and 
this  is  true  both  in  the  acute  and  chronic  variety  of  alcohohsm. 
In  dementia  prsecox,  one  of  the  earhest  symptoms  is  a  tendency 
to  outbursts  of  laughing  for  no  apparent  reason.  On  the 
other  hand,  the  emotions  may  appear  dull  and  fail  to  respond 
to  even  strong  stimuh.  This  is  observed  in  some  cases  of 
melancholia  ;  a  patient  may  be  told  of  the  death  of  a  near  and 
much-loved  relative,  and  be  apparently  unaffected  by  the  news. 


GENERAL  SYMPTOMATOLOGY  69 

Emotional  deficiency  may  result  from  imperception,  as  in  old 
age,  in  arteriosclerosis,  dementia,  myxoedema  and  in  states 
of  mental  enfeeblement.  Again,  fear  and  constant  anxiety 
are  symptoms  frequently  met  with  in  many  types  of  mental 
disorder.  Morbid  emotional  states  may  be  temporary  or  per- 
manent. With  progressive  mental  deterioration  the  emotions 
fail,  together  with  the  other  attributes  of  the  mind. 

Disorders  o£  Volition. — The  layman  is  apt  to  lay  much  stress 
on  the  want  or  weakness  of  will-power  in  the  mentally  afflicted. 
Usually  this  conclusion  is  erroneous  and  there  is  no  real  absence 
of  voHtion,  but  for  the  time  being  it  is  misdirected  or  swayed  by 
disordered  sensations  or  ideas.  There  are  several  disorders 
of  volition  :  (1)  A'praxia,  or  paralysis  of  the  will.  Apraxia  may 
be  either  (a)  sensory  or  (6)  motor  in  character.  In  the  former, 
the  disturbance  is  due  to  failure  on  the  part  of  the  patient  to 
recognise  a  thing.  For  example,  give  him  a  match  and  tell 
him  to  light  a  candle  ;  but  he  makes  no  movement,  as  he  fails 
to  appreciate  that  he  has  a  match  in  his  hand.  If  he  has 
motor  a'praxia  he  recognises  the  match,  but  he  cannot  go  through 
the  movements  required  to  light  it. 

Apraxia  is  a  common  symptom  in  cases  with  cerebral  dege- 
neration, in  Korsakow's  disease,  and  other  types  of  alcoholism, 
and  at  times  in  the  exhaustion  states. 

2.  Negativism  is  another  form  of  disordered  action  ;  in  this 
condition  any  suggestion  made  to  the  patient  at  once  sets  up 
a  counter  suggestion,  and  this  makes  him  resist  everything  done 
for  him.  It  is  a  common  symptom  in  certain  types  of  dementia 
prsecox.  The  reverse  of  this  is  echopraxia  and  automatic 
ohedience,  in  which  the  patient  tends  to  imitate  movements 
made  in  front  of  him.  These  are  also  symptoms  common  to 
dementia  praecox.  Stereotyped  movements  are  movements 
which  are  monotonously  repeated,  such  as  swinging  an  arm  or 
leg.  Defendorf  in  his  text  book  on  '  Chnical  Psychiatry,' 
which  is  an  adaptation  of  Kraepelin's  work,  classifies  morbid 
disturhances  of  volition  in  the  following  way  : 

(1)  The  energy  of  the  volitional  impulse  can  be  diminished 
or  increased  ;  (2)  its  release  facilitated  or  impeded  ;  (3)  or  the 
direction  can  be  modified  by  external  or  internal  influences  ; 

(4)  morbid  impulses  can  forcibly  suppress  the  normal  will; 

(5)  or  natural  impulses  can  assume  morbid  forms  ;    (6)  finally, 


70  PSYCHOLOGICAL  MEDICINE 

the  conduct  of  the  insane  is  naturally  influenced  by  all  those 
disturbances  which  occur  in  other  spheres  of  their  mental  life, 
although  the  volitional  process  itself  presents  no  disturbance. 
Eibot,  in  his  '  Diseases  of  the  Will,'  divides  the  disorders  of 
the  will  into  two  principal  groups,  according  as  the  will  is 
impaired  or  abolished.  '  Impairment  of  the  will  may  be  due 
to  (1)  lack  of  impulse,  or  (2)  excess  of  impulse.'  The  former 
variety  is  called  ahoulia  :  meaning  that  the  patient  knows  what 
he  ought  to  do,  but  lacks  the  power  to  bring  his  will  into  action. 
This  condition  is  common  in  some  forms  of  melancholia.  In 
the  second  class,  the  difficulty  is  lack  of  inhibition  and  control. 
Volitional  actions  are  dimiuished  with  fatigue,  intoxication, 
and  with  certain  drugs — such  as  morphia — and  in  several  forms 
of  mental  disorders.  There  is  increase  of  voHtional  impulse 
in  conditions  of  motor  excitement.  The  so-called  latent  period, 
or  period  of  inaction  before  making  the  movement,  may  be 
lengthened  ;  and,  according  to  some  authorities,  this  lengthen- 
ing is  due  to  a  certain  amount  of  resistance  which  has  to  be 
overcome.  This  is  well  seen  in  melancholia.  Attention  has 
much  to  do  with  action ;  inattention  may  play  an  important 
part  in  disorders  of  the  will.  For  this  reason  certain  children 
are  always  inactive.  Obsessions  (compulsive  acts  or  imperative 
ideas)  are  another  variety  of  disorder  of  the  will ;  these  will  be 
fully  dealt  with  in  a  subsequent  chapter. 

Movements. — In  an  earlier  chapter  it  has  been  shown  that 
movements  are  the  muscular  expression  of  mental  action.  It 
has  been  shown  that  in  infancy  movements  are  spontaneous 
and  uncontrolled,  and  that  these  movements  gradually  become 
controlled  as  childhood  advances.  With  dissolution  there  is  a 
reversion  to  this  former  state.  The  restlessness  of  delirium 
and  mania  belongs  to  this  class,  and  even  the  fidgety  move- 
ments so  common  with  fatigue  must  be  regarded  as  falling  into 
the  same  category.  All  through  the  day  we  are  slowly  passing 
from  a  higher  to  a  lower  state  of  evolution,  and  it  is  only  with 
rest  and  sleep  that  the  equilibrium  is  re-established.  With  the 
agitated  melancholiac  there  is  often  constant  movement. 

Stoddart  has  drawn  attention  to  a  marked  difference  in  the 
movements  of  persons  suffering  from  mania  as  compared  with 
those  of  the  melancholiac.  He  has  pointed  out  that  the 
maniac's  movements  are  chiefly  from  the  large  joints,  while 


GENERAL  SYMPTOMATOLOGY  71 

those  of  the  melancholiac  are  principally  connected  with  the 
fingers  and  smaller  joints.  This  is  a  very  important  observation 
and  when  considered  with  the  microkinesis  of  infancy  it  shows 
how  strong  the  relationship  really  is  between  the  movements 
in  the  early  states  of  evolution  and  those  of  dissolution.  Ehyth- 
mical  movements  are  also  common  in  the  insane,  notably  in 
catatonic  and  some  depressed  states.  Delusions  may  be  shown 
by  movements,  for  some  patients  constantly  mirror  their 
thoughts  by  their  actions. 

Impulsive  Acts. — Impulsive  actions  take  place  during  pas- 
sive attention,  and  have  to  be  distinguished  from  voluntary 
or  volitional  acts,  which  occur  during  active  attention.  Obses- 
sions or  imperative  ideas  are  largely  associated  with  active 
attention,  and  may  in  time  monopolise  the  whole  attention. 
Thus  a  difference  is  to  be  observed  between  a  purely  impulsive 
act  and  an  imperative  idea.  Below,  we  refer  to  the  common 
forms  of  impulse  met  with  in  the  insane.  These  are  very  varied, 
and  may  result  in  injury  to  self  or  others.  Morbid  impulses  may 
be  exhibited  in  sexual  desires,  or  in  an  irresistible  impulse  to 
steal  or  set  fire  to  everything.  Excessive  greed  and  a  desire  to 
eat  all  manner  of  disgusting  things  belong  also  to  this  category. 

Impulsive  acts  are  numerous.  The  following  are  the  types 
given  by  Clouston  :  (1)  General  impulsiveness,  or  the  tendency 
to  react  immediately  to  all  sorts  of  external  or  internal  stimuli. 
(2)  Epileptiform  impulses  which  are  unconscious  in  character  ; 
or  in  which,  at  any  rate,  the  patient  is  unable  to  recall  the 
reason  for,  or  the  nature  of,  the  impulsive  act.  (3)  Sexual 
impulses  of  all  kinds.  (4)  Morbid  appetites,  in  which  the 
patients  are  unable  to  resist  eating  and  drinking  all  sorts  of 
filth.  (5)  Homicidal  impulses.  (6)  Suicidal  impulses.  (7) 
Dipsomania,  kleptomania,  pyromania,  etc.  (8)  Impulsive 
conditions  which  alternate  with  forms  of  intellectual  and  moral 
insanity. 

Exaltation.  —  In  mental  disease,  the  term  '  exaltation ' 
denotes  delusions  of  grandeur,  wealth,  and  importance  ;  it 
must  be  distinguished  from  excitement,  which  is  quite  a 
different  mental  state.  The  tendency  of  the  casual  observer 
is  to  diagnose  an  exalted  person  as  suffering  from  general 
paralysis.  Consideration  of  this  disease  will  show  that  it  is  a 
physical  derangement,  and  that  the  mental  symptoms  are  to 


72  PSYCHOLOGICAL  MEDICINE 

a  certain  extent  accidental,  and  referable  to  the  ravages  of  the 
disease  upon  the  brain.  In  some  cases  of  general  paralysis 
there  are  no  marked  mental  changes  for  a  long  time,  and  then 
merely  a  progressive  dementia.  Any  form  of  mental  dis- 
order may  be  encountered  in  general  paralysis,  depression 
being  almost  as  common  as  exaltation.  The  student  must 
therefore  be  careful  not  to  fall  into  the  common  error  of 
diagnosing  general  jjaralysis  from  the  symptom  of  exaltation, 
which  is  common  to  many  forms  of  insanity. 

Exaltation  is  merely  a  mental  state,  and  it  is  to  be  found 
frequently  in  the  following  varieties  of  mental  disorder : 
(1)  simple  mania  ;  (2)  chronic  mania  ;  (3)  paranoia  ;  (4)  de- 
lusional insanity  ;  (5)  certain  forms  of  alcoholic  insanity ; 
(6)  some  varieties  of  epileptic  insanity  ;  (7)  some  cases  of  de- 
mentia ;  and  (8)  general  paralysis  of  the  insane.  Exaltation, 
at  times,  seems  to  grow  out  of  a  natural  tendency  to  be  ego- 
tistical, and  later  passes  on  to  inordinate  conceit  and  self- 
complacenc}^  The  patients  are,  as  a  rule,  youthful  in  such 
cases  ;  nevertheless  they  believe  themselves  to  be  possessed  of 
wonderful  powers.  They  consider  themselves  to  be  talented 
beyond  their  fellows,  especially  in  subjects  such  as  poetry, 
drama,  or  composition.  In  others,  the  exaltation  has  developed 
after  a  varying  period  of  delusions  of  persecution.  The 
patient  begins  to  ask  himself  why  every  one  stares  at  him, 
why  he  is  always  recognised  in  the  street,  why  he  is  talked 
about  ?  Sooner  or  later  the  answer  comes — '  It  must  be  that  I 
am  some  one  great.'  There  are  some  cases  in  which  exaltation 
is  merely  an  exaggerated  sense  of  well-being  ;  in  others  it  is, 
as  Bavage  graphically  puts  it,  '  the  mast  sticking  up  when  the 
ship  has  gone  down  ' — in  other  words,  the  last  remnant  of  a 
mind  now  completely  disorganised. 

Habits. —It  has  already  been  observed  that  the  law  of 
habit  is  a  form  of  the  law  of  association.  If,  for  example,  we 
begin  to  doubt  the  intentions  of  those  around  us,  in  time  it 
will  become  second  nature  to  us  to  treat  with  suspicion  every 
one  with  whom  we  come  in  contact.  The  insane  are  very 
liable  to  develop  bad  habits,  and  these  frequently  interfere 
with  (he  prospect  of  recovery  ;  for  a  patient  may  learn  to  base 
the  workings  of  his  whole  life  on  these  habits,  and  in  such 
a  case  their  eradication  will  be  found  to  be  almost  impossible. 


GENERAL  SYMPTOMATOLOGY  73 

On  the  other  hand,  there  are  a  number  of  habits  which  it  is 
possible  to  break  down,  and  those  in  charge  of  the  insane  should 
constantly  endeavour  to  encourage  the  patient  to  correct 
them.  Biting  the  nails  is  a  sign  of  irritability  and  restless- 
ness. Some  patients  are  constantly  removing  their  clothing, 
not  necessarily  with  the  intention  of  exposing  themselves, 
but  rather  from  a  desire  to  be  free  from  all  covering,  which 
seems  to  irritate  the  skin.  Others  will  dress  themselves 
in  an  extravagant  way,  and  decorate  themselves  with  flowers 
or  bright-coloured  ribbons.  In  certain  forms  of  insanity  the 
mental  state  seems  to  revert  to  the  early  schooldays,  when  all 
manner  of  rubbish  was  collected  and  stowed  away  in  the 
pockets.  The  aesthetic  sentiment  may  be  diminished  or  lost, 
the  patient  may  become  careless  of  dress  and  general  appear- 
ance, or  he  may  show  great  extravagance  and  squander  money 
in  a  reckless  manner. 

Destructiveness  of  all  kinds  is  common  in  the  insane.  Some 
destroy  with  the  intention  of  constructing  something  new  out 
of  the  remnants,  but  they  never  get  further  than  the  destruction 
of  the  original  article.  Others  destroy  in  a  reflex  impulsive 
manner  and  often  will  tell  you  that  it  is  a  great  relief  to 
throw  things  down  or  break  something.  Eavenous  eating 
is  another  habit  which  should  be  corrected.  This  symptom 
may  be  due  to  irritability  and  loss  of  control — the  patient  not 
giving  himself  time  to  eat  a  meal — or  it  may  be  the  result  of 
an  inordinately  large  appetite.  Eating  all  kinds  of  rubbish 
and  picking  pieces  of  food  from  the  waste-bowl  is  a  habit  of 
some  patients — this  is  usually  a  symptom  of  degeneracy,  and 
few  of  those  who  practise  it  recover.  Some  patients  will  not 
attend  to  the  calls  of  nature— this  may  be  wilful  neglect,  or 
due  to  general  mental  confusion. 

Sexual  malpractices  are  also  common  in  the  insane.  Mas- 
turbation is  a  frequent  symptom  both  in  the  male  and  in  the 
female.  It  is  a  practice  that  is  often  looked  upon  as  a  cause 
of  mental  disorder.  Probably  this  is  the  case  in  a  certain 
percentage  of  neurotic  individuals,  but  it  is  far  more  often  a 
symptom  of  mental  disease.  Masturbation  may  be  merely  a 
vice  learned  at  school,  or  in  some  cases  a  child  first  begins  to 
practise  it  as  it  finds  that  it  relieves  tension  when  pressed  with 
work,    the  writer  has  seen  several   cases   of   this   kind.     No 


74  PSYCHOLOGICAL  MEDICINE 

definite  age  can  be  fixed  for  talking  to  young  persons  on  sexual 
matters,  as  some  children  are  more  precocious  than  others  ;  but 
it  is  most  important  for  those  who  have  the  charge  of  them  to 
be  very  watchful,  and  not  hesitate  to  speak  if  they  observe 
any  suggestive  symptom.  With  care,  it  is  quite  easy  in  a 
conversation  to  see  if  a  boy  understands  what  is  being  referred 
to  ;  and  if  it  is  noticed  that  he  is  ignorant,  the  subject  can  be 
changed  at  once.  Many  youths  are  greatly  relieved  at  having 
a  chance  of  being  able  to  speak  to  some  one  on  the  subject, 
as  not  infrequently  they  have  already  been  frightened  by 
reading  quack  literature.  It  should  be  clearly  pointed  out 
to  the  boy  that  to  contmue  masturbation  is  to  run  the  risk  of 
midermining  his  whole  constitution  and  ruining  himself  in 
mind  and  body.  On  the  other  hand,  his  mind  should  be  set 
at  rest  by  telling  him  that  up  to  the  present  no  permanent 
harm  has  been  done,  and  that  if  he  conquers  the  habit  he 
will  soon  be  strong  and  well  again. 

Except  in  the  case  of  very  neurotic  subjects,  masturbation 
does  not  cause  mental  disorder  ;  it  chiefly  produces  apathy  and 
general  Hstlessness,  and  at  times  leads  to  tremor  of  the  face 
dming  speech.  If  carried  to  excess  there  are  marked  symptoms 
of  fatigue  and  the  pupils  are  usually  widely  dilated.  In  the 
insane,  masturbation  is  a  very  trying  symptom,  and  most 
difficult  to  treat.  Other  sexual  malpractices  are  not  uncommon 
in  very  degenerate  types  of  mental  disorder,  and  especially 
in  some  forms  of  paranoia.  These  cases  are  important  from 
a  medico-legal  aspect,  as  the  sufferers  may  place  themselves 
within  reach  of  criminal  law.  It  is  often  very  difficult  to  defend 
these  persons,  as,  with  the  exception  of  inordinate  conceit, 
it  is  often  impossible  to  find  any  other  symptom.  Their 
mental  aberration  is  shown  entirely  by  disorders  of  conduct, 
and  they  are  therefore  hardly  distinguishable  from  the  ordinary 
ci'iminal.  Nevertheless  it  is  the  duty  of  the  physician  to  defend 
these  persons  if  he  considers  them  to  be  victims  of  nervous 
dcgonoracy  and  not  degraded  criminals. 

Suicide. — Suicidal  tendencies  are  so  very  common  in  the 
insane  that  the  subject  must  be  included  in  a  chapter  on 
General  Symptomatology.  The  question  of  suicide  is  a  very 
large  one,  and  has  exercised  the  minds  of  men  since  the  very 
earliest  times.  In  some  periods  of  history  suicide  was  not  only 
permitted  under  certain  circumstances,  but  was  even  expected 


GENERAL  SYMPTOMATOLOGY  '  75 

as  the  natural  sequel  of  some  events.  Formerly  the  '  happy 
despatch  '  was  the  customary  end  of  a  Japanese  who  had 
compromised  himself  either  ojBicially  or  socially.  Space  will 
not  permit  a  general  review  of  this  subject,  nor  is  such  a  survey 
required  in  a  book  of  this  kind,  where  the  study  of  the  relation- 
ship of  suicide  to  insanity  is  all  that  is  relevant.  The  tendency 
to  suicide  varies  in  different  forms  of  mental  disorder,  but  it  is 
most  rife  in  states  of  depression — indeed,  it  is  not  too  much  to 
say  that  every  melanchohac  must  be  looked  upon  as  a  potential 
suicide.  Suicide  may  be  accidental  or  intentional.  A  maniac 
or  general  paralytic  may  accidentally  kill  himself  in  an  attempt 
to  perform  some  impossible  feat.  Another  patient  may 
actually  destroy  his  Hfe  when  his  intention  was  merely  to 
attract  the  sympathy  of  others  or  to  draw  attention  to  his 
case.  Patients  suffering  from  the  extreme  forms  of  nerve 
exhaustion  are  peculiarly  hable  to  commit  suicide.  The  more 
fatigued  they  become,  the  more  marked  the  mental  compulsion 
and  the  greater  the  danger  of  impulsive  acts.  Many  of  the 
suicides  in  nursing  homes  are  by  patients  of  this  type. 

The  reasons  given  for  attempts  at  self-destruction  are  so 
varied  that  it  would  be  impossible  to  enumerate  them.  Among 
the  common  reasons  assigned  by  would-be  suicides  the  following 
may  be  recorded  :  (1)  that  they  are  unfit  to  live  ;  (2)  that  they 
are  ruined  morally  or  financially  ;  (3)  that  they  are  a  source 
of  danger  or  contamination  to  the  rest  of  the  community  ; 
(4)  that  they  may  avoid  constant  persecution  ;  (5)  that  they 
are  impelled  to  do  so  by  '  voices '  urging  suicide ;  (6)  that 
various  delusions  compel  suicide  ;  f7)  sleeplessness  ;  (8)  during 
mental  confusion  (exhaustion  states)  ;  (9)  continual  worry  ; 
(10)  that  others  may  be  saved,  etc.  A  certain  number  of 
patients  act  purely  on  impulse  ;  suicide  suggests  itself  in  some 
form,  and  is  at  once  carried  into  effect.  Similarly,  a  man 
may  destroy  himself  in  a  fit  of  passion — this  is  at  times  met 
with  in  the  case  of  epileptics.  Children  frequently  commit  or 
attempt  suicide,  and  the  triviahty  of  the  motive  given  is  often 
extraordinary. 

The  methods  employed  for  self-destruction  vary  in  different 
individuals.  The  most  dangerous  class  are  those  who  spend 
their  time  in  devising  numerous  plans,  and  who  would  avail 
themselves  of  any  possible  means  of  carrying  out  their  mten- 
tions.    The  average  person  prefers  some  particular  method  which 


76  PSYCHOLOGICAL  MEDICINE 

specially  appeals  to  him.  For  instance,  a  man  has  been  known 
to  swim  a  river  to  reach  a  railway,  in  order  to  throw  himself 
in  front  of  some  passing  train.  This  peculiarity  is  of  great 
importance  in  the  treatment  of  suicidal  persons,  though  it 
is  dangerous  to  rely  on  the  patient  adhering  absolutely  to  his 
chosen  plan. 

There  is  Uttle  doubt  that  a  far  larger  number  of  persons 
contemplate  self-destruction  than  are  actively  suicidal.  After 
all,  it  is  not  surprising  that  suicide  should  suggest  itself  to  the 
depressed  and  worried  mind.  It  is  natural  that  the  troubled 
soul  should  seek  that  portal  which,  once  passed,  ends  for  ever 
the  sufferings  of  mortahty  ;  for  the  truly  depressed  person 
usually  feels  that  he  has  nothing  to  hope  for  in  this  world  or  the 
next.  The  physician  need  never  fear  that  by  asking  a  person 
whether  he  has  suicidal  feelings  he  may  be  making  the  first 
suggestion  of  self-destruction  to  the  patient's  mind.  Not 
only  is  there  no  such  risk,  but  it  is  the  duty  of  the  physician 
to  talk  to  a  depressed  patient  on  this  question.  It  is  a  subject 
fi'om  the  discussion  of  which  most  persons  recoil,  and  to  which 
they  will  not  initiate  any  reference  ;  but  it  is  often  a  great 
reUef  that  it  should  be  opened  by  another.  The  thought 
of  suicide  is  one  which  is  accompanied  by  intense  suffering ; 
not  merely  the  suffering  which  has  suggested  suicide  as  a 
means  of  escape,  but  also  that  which  is  engendered  by  the 
feeling  that  even  the  contemplation  of  self-destruction  is  a 
grievous  sin.  If  the  physician  explains  that  the  desire  to 
commit  suicide  is  quite  a  common  symptom  with  depression, 
and  tells  his  patient  that  he  should  speak  as  freely  about  any 
suicidal  impulse  as  he  would  about  any  physical  symptom,  he 
will  almost  sm'ely  relieve  both  his  patient  and  help  those  who 
look  after  him.  Suicide  is  most  likely  to  occm-  in  the  early 
morning,  between  5  a.m.  and  10  a.m.  Between  those  hom'S 
the  melanchoUac  is  most  depressed  and  ought  to  be  kept 
under  strict  supervision.  In  patients  with  nerve  exhaustion 
the  latter  part  of  the  day  is  equally  dangerous  from  the  suicidal 
standpoint. 

With  regard  to  the  question  whether  a  suicide  fully  realises 
the  nature  of  his  act,  it  is  probable  that  the  majority  of 
persons  attempt  to  destroy  themselves  when  in  a  confused 
condition  of  consciousness — in  fact,  almost  in  a  dream  state. 


GENERAL  SYMPTOMATOLOGY  77 

Probably  the  idea  of  suicide  has  been  uppermost  in  their  minds 
for  a  long  time  ;  maybe  they  have  been  fighting  against  the 
feeling  ;  and  ultimately,  in  a  semi-confused  state,  the  act,  is 
done  or  attempted.  It  is  interesting  to  note  that  immediately 
after  a  would-be  suicide  has  committed  the  act,  he  may,  if 
a  fatal  result  does  not  at  once  ensue,  try  to  save  himself ;  and, 
if  he  be  successful  in  so  doing,  the  incident  often  proves  the 
turning-point  in  the  illness,  and  from  that  moment  he  may 
make  an  uninterrupted  recovery. 

Homicide. — There  is  probably  no  insanity  in  which  the 
desire  to  kill  stands  as  the  only  symptom.  Homicidal  feelings 
are  by  no  means  as  common  as  the  lay  mind  would  suppose, 
and  the  percentage  of  dangerously  homicidal  patients  is 
decidedly  low  in  any  asylum,  save  in  the  criminal  asylum  at 
Broadmoor.  On  the  other  hand,  impulsive  violence  is  common, 
but  only  a  small  percentage  of  patients  with  this  symptom  can 
be  looked  upon  as  homicidal.  The  really  dangerous  man  is  he 
who  quietly  awaits  his  chance,  plotting  and  scheming  for  days 
before  he  carries  his  intentions  into  execution.  The  writer  has 
heard  a  patient  say  that,  owing  to  the  continual  persecution 
to  which  he  had  been  subjected,  he  felt  perfectly  justified 
in  killing  the  man  whom  he  believed  to  be  his  persecutor. 
Many  homicidal  persons  are  fully  aware  that  it  is  against  the 
law  of  the  land  that  they  should  murder,  and  may  even  recog- 
nise that  they  may  have  to  pay  the  penalty  society  exacts. 
Another  patient  told  the  writer  that  he  intended  to  kill  two 
persons  who  had  wronged  him,  adding,  '  I  know  that  I  may 
be  hanged  myself,  but  after  all  it  will  be  two  lives  for  one.' 
Perhaps  the  most  dangerous  type  of  insanity  is  the  mental 
disorder  which  follows  a  major  or  minor  attack  of  epUepsy, 
and  more  especially  the  latter,  acts  of  violence  being  very 
common  dm-ing  the  automatic  stage  which  follows  the  fit. 
The  melancholiac  may  murder  his  whole  family  before  he 
commits  suicide,  as  he  will  not  leave  them  to  starve. 

In  some  cases  the  homicidal  impulse  seems  to  be  of  the 
nature  of  an  obsession,  for  the  idea  to  kill  usurps  the  whole 
attention.  With  these  persons  the  attack  is  generally  very 
sudden  and  determined.  *  Voices  '  may  urge  a  man  on  to 
murder.  Some  years  ago  when  a  gentleman  was  walking  up 
Begent  Street  he  heard  a  '  voice  '  telling  him  that  he  must 


78  PSYCHOLOGICAL  IklEDICINE 

kill  some  one  at  once.  He  ignored  it  for  some  time,  but  the 
commands  became  more  urgent  and  the  phenomenon  being 
so  extraordinary,  he  began  to  lose  confidence  in  himself.  As 
matters  were  nearing  a  crisis,  the  '  voice  '  gave  him  an  alter- 
native, and  the  order  was,  '  You  must  at  once  kill  some  one 
or  go  to  an  asylum.'  He  was  relieved  to  find  any  way  of 
escape,  and  at  once  hailing  a  hansom,  told  the  man  to  drive 
to  the  nearest  asylum.  He  reached  Bethlem  in  an  agitated 
condition  and  begged  that  he  might  be  taken  in  as  a  voluntary 
boarder.  The  patient  remained  in  the  hospital  for  about  six 
weeks  and  was  then  discharged  recovered. 

At  times  the  desire  to  kill  may  take  the  form  of  a  periodic 
impulsive  insanity  and  may  resemble  dipsomania  in  its  manner 
of  onset.  These  patients  may  confide  their  troubles  to  their 
friends  or  medical  attendant,  and  it  is  important  to  remember 
that  these  confidences  must  not  be  treated  too  hghtly.  The 
very  fact  that  a  man  will  own  to  such  terrible  thoughts  proves 
the  intensity  of  them  in  his  mind.  Many  a  murder  might  have 
been  prevented  had  some  one  only  given  the  patient  the 
assistance  which  he  sought.  There  is  another  point  which 
is  worth  remembering  regarding  the  treatment  of  would-be 
mm'derers.  If  an  insane  man  has  a  grievance,  listen  to  him 
and  argue  with  him  in  a  liberal  manner  if  yo.u  hke,  but  never 
turn  away  and  refuse  to  hear  what  he  has  to  say.  A  sane  man 
is  intensely  annoyed  if  he  is  treated  in  what  he  considers  to  be 
a  high-handed  way  ;  but  the  insane  man  may  lose  all  control 
and  make  a  violent  assault,  which  would  probably  not  have 
been  made  had  he  received  what  he  regarded  as  a  fair  hearing. 
You  are  perfectly  at  liberty  after  the  interview  to  inform  the 
man's  friends  or  the  police  that  3-ou  consider  him  to  be  a  danger- 
ous person.  Many  fatal  assaults  might  have  been  avoided  if 
people  would  remember  to  treat  the  man  with  a  grievance  in  a 
courteous  manner.  The  question  of  homicide  will  be  further 
dealt  with  in  the  chapter  on  the  Eelationship  of  Insanity  to 
Law. 

Fatigue. — Fatigue  states  are  of  vast  importance  to  the 
student  who  studies  mental  disorder,  as  they  are  his  great  oppor- 
tunities for  investigating  mental  disturbances  in  their  earliest 
form.  The  time  when  fatigue  symptoms  first  appear  varies 
in  different  individuals  ;  one  man  wearies  more  readily  on  the 


GENERAL  SYMPTOMATOLOGY  79 

muscular  side,  another  on  the  intellectual.  Some  persons, 
as  they  fatigue,  at  first  exhibit  a  greater  capacity  for  work 
and  may  ultimately  collapse  suddenly  ;  others  progressively 
fail.  Fatigue  m&j  be  ushered  in  by  some  disorder  of  sensa- 
tion in  a  feeling  of  lightness  or  heaviness  of  the  limbs,  or  the 
special  senses  may  evince  disturbances — such  as  illusions  or 
hallucinations  of  sight  or  hearing.  With  fatigue  there  is 
loss  of  power  of  attention  ;  association  is  diminished,  and  the 
hearing  is  defective.  Weak  stimuli,  which  in  a  normal  state 
would  have  been  unnoticed,  now  become  painfully  unpleasant. 
Every  one  has  probably  experienced  how  annoying  the  ticking 
of  a  clock  or  the  rattling  of  a  window  may  be  when  he  has 
been  exceptionally  tired.  With  fatigue  the  reaction  time  is 
longer,  and  the  subject  will  give  a  large  number  of  premature 
reactions — that  is  to  say,  he  will  react  before  the  signal  has 
been  given.  The  pupils  may  be  found  to  be  widely  dilated, 
and  the  deep  reflexes  are  usually  exaggerated. 

Fine  muscular  adjustment,  such  as  writing,  fails ;  the 
handT\Titing  is  changed  and  shows  mental  irritability.  With 
fatigue  we  find  both  increasing  irritability  and  restlessness. 
With  irritability,  muscular  movements  will  be  found  to  be 
irregular  and  spasmodic.  The  judgment  is  inaccurate  and 
unreliable,  and  there  are  outbursts  of  temper  on  the  slightest 
provocation.  Irritabilit}^  is  to  be  observed  in  the  early  stages 
of  many  forms  of  mental  disorder  and  ought  to  be  the  warning 
note  that  rest  is  necessary.  Quick  temper  and  great  irritability 
are  often  the  earliest  mental  changes  in  general  paralysis. 

Restlessness  is  a  very  important  symptom,  and  one  that 
does  not  always  receive  the  attention  due  to  it.  With  mental 
fatigue  there  is  almost  always  restlessness ;  the  student 
reading  for  an  examination  will  note  this,  for  no  sooner  has 
he  sat  down  to  read  than  Ms  attention  wanders,  and  he  gets 
up  and  does  something  else.  The  weary  busy  man  paces  up 
and  down  his  office  trying  to  concentrate  his  thoughts,  and 
the  more  exhausted  he  is  the  more  energetic  he  seems  to 
become.  Few  seem  to  realise  that  this  morbid  restlessness 
is  almost,  if  not  actually,  within  the  danger-zone  which  separates 
sanity  from  insanity.  There  is  no  symptom  which  requires 
more  immediate  attention.  When  we  finally  cross  the  line 
and  enter  the  realms  of  insanity,  restlessness  is  a  common 


80  PSYCHOLOGICAL  MEDICINE 

and  prominent  symptom,  especially  in  such  disorders  as  mania 
and  agitated  melancholia. 

Jealousy. — In  primitive  life  jealousy  is  closely  associated 
with  sex.  The  male  is  jealous  of  the  female,  and  the  female 
for  the  welfare  of  her  offspring.  As  society  becomes  more 
complicated,  jealousy  is  found  in  many  other  phases  ;  but  it  is 
still  in  sex  relationship  that  it  plays  the  most  prominent  part. 
As  a  symptom  of  mental  disorder  it  is  by  no  means  uncommon, 
and  a  very  trying  symptom  it  is  to  those  who  may  be  the 
objects  of  its  attention.  It  is  far  more  common  among  women 
than  men,  and  in  the  mental  disorder  of  some  unmarried 
women  and  in  widows  jealousy  frequently  plays  an  important 
part.  These  women  generally  select  some  man,  commonly  a 
clergyman  or  some  young  physician,  and  continually  dog  his 
path.  If  there  is  any  obstacle  in  the  form  of  another  lady 
in  the  way,  murder  has  been  known  to  result.  Women  of  this 
type  have  no  shame ;  indifference  and  even  definite  objection 
on  the  part  of  the  victim  make  no  difference.  The  devotion 
is  steadily  maintained.  This  form  of  mental  disorder  is  often 
most  difficult  to  treat.  There  is  nothing  to  which  one  may 
point  except  their  extraordinary  conduct ;  and  even  this  may 
not  be  so  marked  as  might  be  expected,  as  they  show  much 
cunning  in  preventing  attention  being  drawn  to  their  actions. 
Their  conversation,  though  foolish  and  extravagant  at  times, 
cannot  be  considered  as  more  than  eccentric.  Many  a  man 
has  been  seriously  compromised  by  a  woman  of  this  type, 
notwithstanding  every  effort  on  his  part  to  escape  her  devotion. 
These  cases  are  not  understood  by  the  lay  mind.  There  is 
always  a  strong  disposition  to  champion  the  cause  of  a  woman  ; 
the  charitable  pubUc  is  ever  ready  to  point  the  finger  of  scorn 
and  to  hound  a  man  out  of  society,  without  even  hearing  his 
defence.  No  more  trying  fate  can  befall  a  young  man  than 
to  find  himself  the  object  of  regard  of  an  insane  woman  of  this 
kind.  The  friends  of  such  a  woman  should  at  once  be  told  of 
the  annoyance  which  her  conduct  occasions  ;  letters  received 
and  copies  of  all  letters  written  should  be  carefully  kept. 

Further  reference  will  be  made  to  jealousy  in  the  descrip- 
tion of  the  mental  disorders  of  the  climacteric  period.  A 
mother  may  be  jealous  of  her  children  ;  and  an  insane  parent 
has  been  known  to  murder  a  child  in  order  to  spite  his  wife 


GENERAL  SYMPTOMATOLOGY  81 

or  her  husband,  as  the  case  may  be.  Cases  at  tnnes  occur 
where  a  young  man  is  insanely  jealous  of  some  girl  who  refuses 
to  marry  him,  and  she  not  infrequently  falls  a  victim  to  his 
jealousy.  Jealousy  may  occur  alone  or  associated  with  other 
symptoms  of  mental  disorder.  In  any  case,  it  is  useless  to 
attempt  home  treatment  if  the  patient  is  jealous  of  any  relative 
residing  in  the  house.  The  only  prospect  of  recovery  is  in 
getting  the  patient  away  from  the  customary  surroundings. 

Heart  and  Vascular  System. — Heart  disease  is  not  more 
common  among  the  insane  than  the  sane,  and  the  causes  are 
the  same  in  both.  If  a  person  with  aortic  regurgitation 
becomes  insane,  the  form  the  mental  disorder  takes  is  usually 
that  of  excitement  and  restlessness — as  in  mania  or  agitated 
melancholia.  In  the  case  of  mitral  disease,  especially  during 
■the  early  stages,  the  mental  state  is  usually  one  of  depression. 
The  arterial  tension  varies  in  different  forms  of  insanity,  and 
is  a  symptom  of  much  diagnostic  value.  The  writer  made  a 
careful  study  of  the  blood-pressure  in  the  insane.  The  results 
of  this  work  were  published  in  the  '  Lancet,'  June  25,  1898, 
and  the  following  were  the  deductions  arrived  at  : — ■ 

1.  That  the  blood-pressure  varies  in  certain  forms  of  insanity. 

2.  That  the  blood-pressure  is  raised  in  persons  who  are 
depressed,  or  who  are  suffering  from  melancholia. 

3.  That  the  blood-pressure  gives  varied  results  in  persons 
suffering  from  melancholia  with  motor  excitement,  so-called 
agitated  melancholia.  (The  writer  has  made  further  investiga- 
tions in  this  form  of  insanity  and  has  found  that  the  blood- 
pressure  is  almost  invariably  low,  and  for  this  reason  he 
considers  that  agitated  melancholia  ought  to  be  classed  with 
mania.) 

4.  That  the  blood-pressure  is  found  to  be  normal  upon  the 
recovery  of  a  patient  whose  blood-pressure  has  been  raised 
during  the  period  of  depression. 

5.  That  the  blood-pressure  is  lowered  in  persons  suffering 
from  excitement  or  acute  mania. 

6.  That  the  blood-pressure  is  found  to  be  normal  after  the 
excitement  has  passed  off  and  the  patient  has  recovered. 

7.  That  the  blood-pressure  tends  to  fall  as  the  day  advances  ; 
hence  the  melancholiac  tends  to  improve  throughout  the  day, 
and  the  excited  patient  to  become  more  excited. 

6 


82  PSYCHOLOGICAL  MEDICINE 

8.  That  the  depression  following  on  an  attack  of  acute 
mania  is  not  necessarily  an  active  depression  but  rather 
a  reaction  and  condition  of  exhaustion,  and  that  the  blood- 
pressui'e  in  these  cases  may  remain  low,  until  it  finally  on 
recovery  returns  to  normal. 

9.  That  the  blood-pressure  is  low  in  stupor. 

10.  That  the  blood-pressure  is  not  always  altered  in 
delusional  insanity,  except  in  those  cases  where  there  is  also 
some  emotional  disturbance. 

11.  That  the  blood-pressm'e  in  healthy,  active,  and 
excitable  persons  is  low  compared  with  the  healthy  but 
apathetic  individual. 

12.  That  from  the  above  it  would  appear  that  the  blood- 
j)ressm"e  is  chiefly  affected  in  the  emotional  insanities,  in 
contradistinction  to  the  ideational  forms  of  mental  disorder. 

13.  That  the  blood-pressure  is  raised  in  general  paralysis  of 
the  insane  when  there  is  depression,  but  that  in  the  excited 
types  of  this  disease  the  blood-pressure  is  low,  as  it  is  also 
in  the  later  stages  of  all  types  of  general  paralysis. 

14.  That  there  is  evidence  to  prove  that  the  altered  blood- 
pressure  may  in  certain  individuals  induce  mental  aberration, 
but  that  it  is  so  far  not  complete  enough  to  justify  a  definite 
statement  that  mental  disease  is  usually  caused  by  altered 
blood-pressure. 

15.  That  the  altered  blood-pressure  in  different  forms  of 
insanity  suggests  the  line  of  treatment  which  may  be  adopted 
in  the  various  kinds  of  mental  disease. 

16.  That  the  feeling  of  weight  and  pressure  on  the  top  of 
the  head,  so  common  a  symptom  in  melancholia,  is  apparently 
vascular  in  origin,  and  is  lessened  or  disappears  when  the 
blood-pressure  is  lowered. 

17.  That  certain  depressed  patients  improve  with  treatment 
by  nitro-glycerine,  Ijut  that  there  is  difficulty  in  keeping  the 
blood-pressure  down  with  this  drug,  as  its  action  is  so 
evanescent. 

18.  That  the  action  of  erythrol  tetra-nitrate  is  more  pro- 
longed and  rehable  and  is  more  powerful  in  lowering  the 
blood-pressure  in  melancholia  than  nitro-glycerine. 

19.  That  the  prolonged  bath  raises  the  blood-pressure,  and 
hence  is  of  more  value  in  the  treatment  of  excited  patients. 


GENERAL  SYMPTOMATOLOGY  83 

Since  publishing  this  I  have  noticed  that  in  all  exhaustion 
states,  no  matter  whether  the  patient  is  excited  or  depressed, 
the  blood-pressure  is  low,  and  this  factor  is  frequently  of  great 
assistance  in  differentiating  between  depression  in  maniacal- 
depressive  mental  disorders  and  depression  in  the  exhaustion 
psychoses.  Also  in  chronic  melanchoHa  the  blood-pressure 
may  fall  after  some  months  of  depression,  and  it  is  of  interest 
to  note  that  with  the  fall  of  blood-pressure  the  feeling-tone 
of  depression  is  less  marked. 

The  frequency  of  the  heart-beat  is  increased  in  several 
forms  of  mental  disease,  and  most  notably  in  acute  mania,  in 
which  disorder  the  pulse-rate  is  not  uncommonly  as  high  as 
140.  On  the  other  hand,  with  profound  depression,  the 
frequency  of  the  heart-beat  may  be  lessened  and  the  general 
circulation  found  to  be  very  sluggish.  The  condition  of  the 
blood  is  also  at  times  markedly  affected,  diminution  of  the 
red  blood-corpuscles  and  deficiency  of  haemoglobin  being 
commonly  observed,  and,  what  is  of  even  greater  interest,  a 
large  increase  of  the  white  corpuscles  is  present  in  some  forms 
of  insanity.  The  coats  of  the  blood-vessels  are  found  to 
be  atheromatous  and  degenerate  in  a  certain  percentage 
of  cases,  and  all  the  changes  due  to  former  syphilis  may  be 
observed. 

Blood. — Bruce  has  kindly  given  me  the  following  epitome 
of  some  of  his  work  on  leucocytosis  in  mental  diseases  : — 

'  A  series  of  observations  made  upon  the  leucocytosis  of 
attendants  and  nurses  in  asylums  shows  that  in  such  persons 
— aU  of  whom  were  well-developed  men  and  women  under 
thirty  years  of  age — there  may  exist  considerable  variations 
in  the  total  number  of  leucocytes  and  in  the  percentage  of 
the  different  leucocytes  present.  In  the  women  the  total 
leucocytosis  varied  between  5,600  and  14,000  per  cubic 
millimetre  and  the  percentage  of  polymorphonuclear  cells 
ranged  from  forty-six  to  seventy-four.  In  the  men  the 
leucocytosis  varied  between  4,000  and  10,000  per  cubic 
millimetre  and  the  polymorphonuclear  percentage  between 
forty-nine  and  seventy-one.  The  differences  between  the 
maximum  and  the  minimum  in  these  cases  are  very  con- 
siderable, and  yet  they  are  quite  insignificant  when  compared 
with  the  variations  which  occur  in  certain  cases  of  insanity. 


84  PSYCHOLOGICAL  MEDICLNE 

'  All  the  observations  recorded  below  are  the  results  of 
continuous  blood  examinations — in  several  cases  extending 
over  a  continuous  period  of  six  months  or  longer  ;  isolated 
observations  being,  in  my  experience,  quite  worthless. 

'  For  purposes  of  description  I  divide  my  cases  of  mania 
into  two  classes  :  (1)  Confusional  Mania — conditions  of 
excitement  with  confusion  and  hallucinations,  dm'ing  the 
acute  period  of  which  the  patient  is  not  mentally  accessible, 
and  which  is  never  complicated  by  alternating  states  of 
depression.     (2)  Mania  of  the  maniacal-depressive  type. 

'  During  a  iirst  attack  of  confusional  mania  there  is  always 
a  hyperleucocytosis,  which  may  rise  as  high  as  40,000  or  50,000 
per  cubic  millimetre,  with  a  high  polymorphonuclear  percen- 
tage, and  an  absence  of  eosinophiles.  In  a  typical  case,  as  the 
excitement  subsides  the  leucocytosis  gradually  falls,  and  within 
a  few  days  eosinophiles  appear.  As  recovery  sets  in,  the  leu- 
cocytosis rises  again  and  the  total  number  of  polymorpho- 
nuclear cells  is  also  increased,  while  there  is  a  temporary  rise 
of  eosinophiles  which  fall  again  as  recovery  is  completed. 
In  all  the  cases  which  recover,  there  is  a  persistent  hyper- 
leucocytosis and  high  polymorphonuclear  total.  How  long 
this  persists  it  is  impossible  to  say,  as  recovered  patients  have 
to  be  discharged  ;  but  in  one  case  which  I  kept  under  obser- 
vation for  six  years  after  discharge,  there  was  still  a  hyper- 
leucocytosis with  a  polymorphonuclear  percentage  of  seventy 
or  over.  In  two  other  cases  these  symptoms  were  still  present 
for  two  years  after  discharge. 

'  If  the  patient  does  not  recover,  the  leucocytosis  falls  to 
10,000  or  below  10,000  per  cubic  millimetre,  with  a  faU  in  the 
polymorphonuclear  cells  and  an  increase  of  large  and  small 
lymphocytes,  and  there  is  no  increase  in  the  eosinophiles. 
Such  cases  generally  pass  into  dementia.  On  the  other  hand, 
if  the  patient  becomes  a  case  of  chronic  mania,  the  leucocyte 
chart  presents  a  series  of  waves  of  hyperleucocytosis  cor- 
responding to  periods  of  exacerbation  of  excitement,  and 
there  are  frequent  increases  in  the  eosinophiles  generally 
corresponding  to  the  periods  following  upon  the  exacerbations 
of  excitement. 

'  In  second,  third,  and  fourth  attacks  of  the  disease  the 
hyperleucocytosis    tends    to    become    less    pronounced.     In 


GENERAL  SYMPTOMATOLOGY  85 

recurrent  cases  of  the  disease,  it  is  the  rule  to  find  a  tendency 
to  hypoleucocytosis  immediately  preceding  a  relapse. 

'  In  mania  of  the  maniacal-depressive  variety,  at  the  onset  of 
the  attack  there  is  always  a  hyperleucocytosis,  which  may  vary 
between  14,000  and  30,000  per  cubic  millimetre,  with  a  high 
polymorphonuclear  percentage.  It  is  a  noticeable  featm-e  that 
the  polymorphonuclear  cells  and  the  blood  plaques,  in  the 
very  earliest  days  of  the  most  acute  attacks,  present  a  well- 
marked  iodophile  reaction.  As  the  excitement  lessens  the 
leucocytosis  falls,  and  the  polymorphonuclear  cells  diminish 
in  number.  If  recovery  follows  upon  the  period  of  excite- 
ment the  cell-changes  are  similar  to  those  which  occur  in 
the  recoveries  from  confusional  mania,  but  after  recovery  is 
complete  the  hyperleucocytosis  gradually  disappears.  If,  on 
.the  other  hand,  depression  follows  immediately  upon  the 
period  of  excitement,  the  onset  of  depression  is  marked  by 
an  increase  in  the  leucocytosis  and  the  polymorphonuclear 
percentage.  Throughout  the  period  of  depression  there  is  an 
ii-regular  hyperleucocytosis,  with  frequent  transient  increases 
of  the  eosinophile  cells.  As  the  attack  passes  off,  the  mono- 
nuclear and  large  lymphocyte  cells  increase  at  the  expense 
of  the  polymorphonuclears.  WhUe,  when  recovery  is  com- 
plete, the  leucocytosis  falls  to  about  10,000  or  12,000  per 
cubic  millimetre,  or  even  lower.  In  no  case  which  I  have 
been  able  to  examine,  was  there  any  abnormal  leucocytosis 
during  the  periods  between  the  attacks. 

'  Cases  of  catatonia  follow  very  closely  the  leucocyte  changes 
of  confusional  mania.  During  the  early  acute  stages  of  the 
disease  there  is  always  a  hyperleucocytosis,  with  an  actual 
increase  in  the  polymorphonuclear  cells.  Just  prior  to  the 
onset  of  stupor,  the  polymorphonuclear  leucocytosis  may  rise 
as  high  as  50,000  per  cubic  millimetre.  Dm'ing  the  period 
of  stupor  there  is  a  more  or  less  continuous  hyperleucocy- 
tosis, and  if  recovery  takes  place  there  is  a  rise  in  both  the 
polymorphonuclear  and  eosinophile  cells.  If  the  patient  does 
not  recover,  the  leucocytosis  gradually  falls,  the  polymorpho- 
nuclear cells  diminish  ;  while  the  lymphocytes,  and,  to  a  lesser 
degree,  the  mononuclear  cells  increase. 

'  In  general  paralysis  there  is  a  sHght  hyperleucocytosis 
in   both   the   first    and   second   stages   of   the    disease,    and 


86  PSYCHOLOGICAL  MEDICINE 

in  acutely  excited  cases  the  hypeiieiicocytosis  is  always 
marked.  In  the  third  stage  of  the  disease  there  is  an  irregular 
hyperleucocytosis  due  to  an  increase  chiefly  of  lymphocytes, 
while  the  poh^morphonuclear  cells  are  actually  and  relatively 
diminished.' 

Respiratory  System.  —  The  respiratory  system  is  not 
markedh^  affected  in  patients  suffering  from  mental  disorder. 
In  mania,  and  in  certain  cases  where  the  frequency  of  pulse- 
rate  is  increased,  it  will  be  found  that  the  normal  ratio 
between  heart-beat  and  respiration  is  lost,  as  the  breathing 
is  not  accelerated  to  any  appreciable  extent.  In  some  forms 
of  insanity,  and  more  especially  in  stupor  and  catatonia,  the 
respiration  is  very  shallow  and  the  movements  of  the  chest 
are  slight.  This  is  of  importance,  as  it  may  tend  to  the 
development  of  phthisis  in  predisposed  persons. 

Some  TNTiters  have  given  the  name  of  '  respiratory  hallu- 
cinations '  to  certain  abnormal  sensations  complained  of  by 
some  patients,  of  which  the  following  are  the  more  common — 
a  feeling  of  inability  to  breathe,  or  being  made  to  breathe  too 
quicklj^  or  too  slowly,  whereas  in  reality  the  respiration  is 
normal. 

Secretory  Disorders.  —  In  melancholia  and  allied  condi- 
tions all  the  secretions  are  diminished  in  quantity.  Stoddart 
has  done  some  very  instructive  and  valuable  work  on  this 
subject.  He  found  that  the  sensible  perspiration  was  greatly 
diminished  or  absent  in  these  cases,  and  further  that  the 
patient,  when  treated  with  jaborandi  or  subcutaneous  injection 
of  pilocarpine,  usually  gave  no  reaction.  On  the  other  hand,  he 
observed  that  with  maniacal  patients  a  similar  dose  produced 
profuse  perspiration  and  salivation.  It  is  further  interesting 
to  note  that  Stoddart  found  that,  if  a  melancholiac  were  treated 
with  erythol  tetra-nitrate  for  some  days,  it  was  then  possible 
to  get  a  reaction  to  pilocarpine  or  jaborandi.  The  saliva  is 
diminished  in  melancholia,  and  this,  together  with  insufficient 
secretion  of  the  digestive  juices,  may  account  for  the  indi- 
gestion and  anorexia  experienced  by  a  certain  proportion  of 
melancholiacs.  The  hydrochloric  acid  in  the  gastric  juice 
varies  and  may  be  either  increased  or  lessened. 

Salivation  in  the  insane  may  result  from  several  causes. 
Nevertheless,  it  may  be  merely  apparent  and  not  real  when 


GENERAL  SYMPTOMATOLOGY  87 

saliva  is  seen''  to  be  constantly  dribbling  out  of  the  corners 
of  the  mouth.  In  these  cases  the  saliva  is  probably  not 
swallowed  owing  to  diminished  reflexes  in  the  jDharynx. 
Excessive  and  continual  masticatory  movements  may,  by  purely 
mechanical  means,  jDroduce  a  very  copious  flow  of  saliva. 
Salivation  may  be  due  to  disease  of  the  central  nervous 
system  and  is  seen  in  certain  cases  of  epilepsy.  The  urine 
is  diminished  in  quantity  in  melancholia  and  seldom 
reaches  more  than  thirty  ounces  per  diem,  whereas  polyuria 
is  common  in  general  paralysis  and  hysterical  cases.-  The 
reaction  is  usually  acid,  but  the  urine  may  contain  a  large 
amount  of  phosphates  in  cases  where  there  has  been  great 
cerebral  excitement.  The  quantity  of  urea  excreted  varies, 
being  diminished  in  depressed  states  and  increased  to  a  small 
extent  in  mania.  The  chlorides,  sulphates,  oxalates,  and 
glycero-phosphates  all  vary  in  amount  in  different  forms  of 
mental  disorder.  Indican  is  rarely  found,  but  should  always  be 
looked  for,  as  it  usually  indicates  auto-intoxication.  Albu- 
minuria is  far  from  being  a  common  symptom  in  mental 
disorder,  but  it  is  met  with  in  a  certain  proportion  of  alcoholic 
patients  and  following  seizures  in  some  cases  of  general 
paralysis  and  epilepsy.  Glycosuria  is  not  so  frequently  found 
as  some  writers  would  indicate,  but  the  question  of  diabetes 
will  be  dealt  with  elsewhere. 

Menstruation. — The  catamenia  are  usualty  disordered  in 
most  forms  of  insanity.  Menstruation  is,  as  a  rule,  absent  in 
melancholia  and  in  many  other  types  of  mental  disease. 
Amenorrhoea  must,  in  the  vast  majority  of  cases,  be  con- 
sidered a  symptom  in  the  course  of  the  insanity,  and  not 
the  cause.  This  is  important  to  remember,  and  the  physician 
would  do  well  to  inform  both  the  patient  and  friends  of  the 
true  state  of  affairs,  as  the  former  is  apt  to  be  worried  and 
anxious,  whereas  the  latter  may  be  over-energetic  in  their 
attempts  to  re-establish  the  function,  under  the  belief  that  its 
absence  is  the  cause  of  the  mental  trouble.  In  some  cases — 
notably  certain  forms  of  mania — there  may  be  metrorrhagia 
or  menorrhagia,  and  the  continued  and  profuse  loss  of  blood 
may  seriously  interfere  with  chances  of  recovery.  Again, 
menorrhagia  and  metrorrhagia  are  probably  the  most  common 
cause  of  exhaustion  in  women,  and  any  tendency  to  these  in 


88  PSYCHOLOGICAL  MEBICINE 

neui'otic  subjects  should  at  once  be  treated.  As  a  general 
rule  the  absence  of  the  catamenia  is  a  favourable  symptom 
in  mental  disease,  and  their  reappearance  not  uncommonly 
indicates  general  mental  and  physical  improvement.  On 
the  other  hand,  re-establishment  of  all  the  functions  when 
unaccompanied  by  mental  improvement  greatly  increases 
the  gravity  of  the  prognosis. 

Constipation. — Reference  has  already  been  made  to  con- 
stipation as  a  cause  of  insanity  ;  it  must  now  be  considered 
as  a  •  symptom  in  mental  disorder.  Stress  has  been  fre- 
quently laid  in  these  pages  on  the  fact  that  the  physical 
health  always  suffers  to  a  greater  or  less  degree  in  every 
form  of  insanity.  Constipation  is  probably  the  most  com- 
mon of  all  sj^mptoms.  In  melancholia  it  is  scarcely  ever 
absent  and  requires  constant  attention.  Constipation  may 
result  from  sluggishness  of  functions  or  deficiency  of  intestinal 
secretions.  In  some  cases  there  is  found  to  be  at  post-mortem 
actual  narrowing  of  the  bowel,  more  especially  in  the  ex- 
haustion psychoses.  In  other  cases  the  fault  may  lie  in  defect 
of  innervation  and  lessened  peristalsis.  Whatever  may  be 
the  cause — and  the  physician  should  discover  the  fault,  if 
possible — constipation  is  a  symptom  which  should  never  be 
forgotten,  as  it  is  a  cause  of  anaemia,  sleeplessness,  and  general 
discomfort,  and  may  even  form  the  basis  of  delusions.  Its 
treatment  will  be  dealt  with  elsewhere. 

Trophic  Disorders. — Nutritional  changes  take  place  in  all 
the  tissues  of  the  body  in  patients  suffe)-ing  from  mental  dis- 
order. One  of  the  earliest  symptoms  of  acute  insanity  is 
loss  of  body  weight.  Too  much  stress  cannot  be  laid  on  this 
point,  as  careful  attention  to  the  weight  of  the  body  is  the 
keynote  of  both  preventive  and  curative  treatment.  Trophic 
changes  take  place  in  the  hair  and  nails,  both  of  which 
become  brittle  ;  the  skin  in  many  of  the  insane  will  be  found 
to  be  dry  and  harsh,  and  pustules  and  small  abscesses  may 
develop.  Bed-sores  may  occur  in  some  patients  in  an  almost 
incredibly  short  space  of  time.  Trophic  changes  in  bones  may 
render  them  liable  to  fracture. 

Haematoma  Auris. — An  effusion  of  blood  may  take  place 
between  the  cartilage  of  the  ear  and  its  perichondrium.  This 
condition  is  known  by  the  term  Hsematoma  Auris  or  Othaema- 


GENERAL  SYMPTOMATOLOGY  89 

toma.  Some  persons  speak  of  it  as  Insane  Ear,  but  this  is  a 
misnomer  for  the  condition  is  fomid  also  in  the  sane — as,  for 
example,  in  some  Bugby  football  players.  It  is  very  com- 
mon among  the  chronic  insane  and  general  paralytics,  and 
its  presence  is  usually  considered  to  indicate  incurable 
mental  disorder.  It  is  almost  always  due  to  some  slight 
injury.  Holding  a  patient's  head  with  one  arm  whilst  feeding 
is  one  of  the  commonest  ways  of  producing  a  haematoma 
auris.  Probably  it  is  owing  to  this  mode  of  origin  that  it 
is  more  frequently  found  in  the  left  than  in  the  right  ear, 
as  most  nurses  hold  the  patient  with  the  left  arm  while 
they  feed  with  the  right  hand.  No  violence  nor  even  rough 
handling  need  have  taken  place,  as  very  slight  manipulation 
is  necessary  to  produce  the  condition  :  patients  may  even 
cause  it  themselves  by  rubbing  the  ear  with  their  hands  or 
against  the  pillow.  When  first  seen  it  is  a  smooth  tense 
swelling,  usually  bright  red  in  colour,  which  occupies  the 
anterior  and  outer  surfaces  of  the  auricle  and  is  limited  to 
the  cartilaginous  parts  of  the  ear.  It  is  tender  to  the  touch. 
The  hsematoma  may  rupture  or  slowly  become  organised  ;  in 
any  case  the  result  is  great  wrinkling  and  puckering  of  the 
ear.  Ford  Eobertson  has  shown  that  hsematoma  auris  is 
brought  about  by  degeneration  of  the  cartilage  of  the  ear, 
the  first  change  being  in  the  cartilage  cells  and  later  the  elastic 
fibres,  which  become  fluid.  Cysts  then  form  near  the  surface 
and  new  vessels  appear  ;  in  time  these  latter  degenerate  and 
the  cysts  become  filled  with  blood.  As  the  haemorrhage  con- 
tinues the  perichondrium  becomes  stripped  off,  and  soon 
the  swelHng  gradually  increases  in  size,  until  the  pressure  is 
sufficient  to  arrest  further  oozing  out  of  the  blood.  The 
proper  treatment  for  this  condition  is  blistering  the  cyst 
with  Hquor  epispasticus,  and  if  this  is  done  early  very  little 
deformity  may  result. 

Anomalies  of  the  Ear. — There  are  many  deformities  of 
the  pinna,  and  these,  taken  with  other  stigmata  of  degenera- 
tion, may  be  of  importance. 

Peterson  describes  the  following  twenty-two  varieties  : — 
1.  Abnormally  implanted  ears  :    they  project  too  far  or  lie 
too  closely,  are  placed  too  high  or  too  low,  too  far  forward 
or  too  far  backward  on  the  head. 


90  PSYCHOLOGICAL  MEDICINE 

2.  Excessively  large  ears  :  (a)  absolutely  too  large  ;  (&) 
relatively  too  large  in  small  or  microceplialic  individuals. 

3.  Ears  which  are  too  small. 

4.  Too  marked  conchoidal  shape  of  the  ear  :  the  details 
of  the  ear  (anthelix  and  crura,  etc.)  are  but  slightly  marked, 
while  the  helix  outlines  the  ear  like  the  rim  of  a  funnel. 

5.  Ears  which  have  a  general  ugly  shape  :  the  breadth 
of  the  upper  part  may  exceed  that  of  the  lower,  and  vice 
versa ;  excessive  length ;  ears  without  lobules  ;  unusually 
short  ears. 

6.  Ear  not  uniform  in  width  ;  usually  a  long  ear  with 
one  or  more  constrictions  in  its  breadth. 

7.  The  Blainville  ear :  asymmetry  of  various  kinds  of 
the  two  ears.  In  most  cases  the  asymmetry  is  due  to 
an  anomaly  of  the  left  ear. 

8.  The  ear  without  lobule  :  there  are  usually  other  de- 
formities of  this  ear  besides  the  absence  of  lobule — such  as 
too  large  a  concha,  prominence  of  the  anthelix,  etc. 

9.  The  ear  with  adherent  lobule  :  the  lobule  is  enlarged, 
adherent,  and  inclines  downward  toward  the  cheek. 

10.  The  Stahl  ear.  No.  1  :  a  series  of  anomalies  of  the  helix. 
The  helix  is  broad,  hke  a  band,  and  coalesces  with  the  cartilages 
of  the  crura  furcata ;  the  fossa  ovahs  and  fossa  scaphoidea 
are  scarcely  to  be  seen ;  the  lower  half  of  the  helix  is  obli- 
terated.    There  are  occasionally  slight  variations  from  this 

type. 

11.  The  Darwin  ear  :  helix  interrupted  where  its  trans- 
verse portion  passes  into  the  descending,  and  at  this  point  is  a 
projection  of  the  rim  above  and  outward,  like  the  pointed  ear 
of  lower  animals. 

12.  The  Wildermuth  ear,  No.  1  :  the  anthelix  projects  so 
far  as  to  form  the  most  prominent  part  of  the  auricle. 

13.  The  ear  without  anthelix  or  crura  furcata. 

14.  The  Stahl  ear,  No.  2  :  multiplication  of  the  divisions  of 
the  crura  furcata,  so  that  there  are  three  instead  of  two  crura. 

15.  AYildermuth's  Astec  ear  :  lobule  wanting  ;  the  whole 
ear  seems  pushed  forward  and  downward  ;  the  crus  superius 
of  the  anthelix  coalesces  with  the  helix,  while  its  crus  anterius 
is  scarcely  perceptible. 

16.  The  Stahl  ear,  No.  8  :    onlv  the  crus  anterius  of  the 


GENERAL  SYMPTOMATOLOGY  91 

crura  furcata  is  present,  while  the  auricle  seems  divided  into 
two  halves  by  a  ridge  from  the  antitragus. 

17.  The  ear  with  double  helix. 

18.  The  ear  with  too  large  or  too  small  a  concha. 

19.  The  ear  with  continuous  fossa  scaphoidea  :  the  fossa 
passes  down  into  the  lobe. 

20.  The  Morel  ear  :  a  form  marked  by  abnormal  develop- 
ment of  the  helix,  anthelix,  fossa  scaphoidea,  and  crura 
furcata,  so  that  the  folds  of  the  ear  seem  obliterated,  and 
the  ear  is  smooth,  larger  than  usual,  often  prominent,  and 
with  thin  edge. 

21.  Ear  misshapen  by  abnormal  cartilage  development : 
here  belong  all  irregular  cartilaginous  growths  and  thicken- 
ings, except  those  caused  by  hsematoma  of  the  ear. 

■  22.  Various  peculiarities,  difficult  to  classify,  are  included 
here — such  as  abnormalities  of  the  semilunar  incisure  of  the 
tragus  and  of  the  meatus,  coloboma  of  the  lobule,  hairiness 
of  the  different  parts  of  the  auricle,  accessory  ears,  clefts,  etc. 

Cranial  Deformities.— Asymmetry. — If  slight,  this  may  be 
of  no  importance,  but  if  to  a  marked  degree  and  associated 
with  other  stigmata  of  degeneration,  it  is  important.  The 
normal  circumference  of  the  skull  is  about  twenty-two  and 
a  half  inches,  and  a  deviation  of  more  than  two  and  a  half 
inches  in  either  direction  must  be  regarded  as  abnormal. 
Nevertheless,  there  are  cases  on  record  of  persons  having 
abnormally  large  or  small  heads  who  are  apparently  intellec- 
tually sound.  The  anterior-posterior  diameter  should  be 
about  seven  and  three-quarter  inches,  and  the  greatest  trans- 
verse diameter  is  normally  about  six  and  one-eighth  inches. 

Stoddart  states  that  the  binauricular  diameter  (calliper 
measurement  from  one  auditory  meatus  to  the  other)  and 
the  length  of  the  face  from  the  root  of  the  nose  to  the  lowest 
part  of  the  chin  should  each  be  about  five  and  a  quarter 
inches  ;  and  the  binauricular  arc  and  naso-occipital  arc  (root 
of  nose  to  occipital  protuberance  measured  over  the  highest 
point  of  the  skull)  should  each  be  about  fourteen  inches. 

Broadly  speaking,  an  individual  is  to  be  regarded  as  ab- 
normal if  his  measurements  differ  more  than  fifteen  per 
cent,  from  the  above,  and  as  a  degenerate  if  the  measurements 
are  more  than  fifteen  per  cent,  below  the  normal. 


92  PSYCHOLOGICAL  MEDICINE 

The  cephalic  index  or  index  of  breadth  is  arrived  at  by 
multiplying  the  breadth  by  100  and  dividing  by  the  length. 

Peterson  describes  eight  well-known  cranial  deformities  : — 

Chemocephalus  is  flat-headedness.  In  this  there  is  flat- 
ness at  the  top  of  the  head.  The  condition  is  also  called 
platicephalus. 

Leptocephalus. — Early  synostosis  of  the  frontal  and  sphenoid 
produces  leptocephalus,  or  narrow-headedness. 

Macrocephalus  is  a  large  head,  usually  due  to  hydro- 
cephalus. 

Microcephalus  is  a  small  head,  due  either  to  aplasia  of  the 
brain  or  premature  synostosis  of  the  sutures  (rarely  the 
latter). 

Oxycephalus,  or  steeple-shaped  skull,  is  due  to  synostosis 
of  the  parietal  with  the  occipital  and  temporal  bones,  with 
compensatory  development  in  the  region  of  the  bregma. 
Another  name  for  this  is  acrocephalus. 

Plagiocephalus,  or  oblique  deformity  of  the  head,  is 
due  to  unilateral  synostosis  of  the  frontal  with  one  of  the 
parietal  bones. 

Scaphocephalus  is  probably  caused  either  by  too  early 
union  of  the  sagittal  suture,  or  by  the  development  of  both 
parietal  bones  from  one  centre.  The  top  of  the  head  is 
keel-shaped. 

Trigonocephalus. — Premature  union  of  the  frontal  suture, 
resulting  in  very  narrow  forehead  and  great  width  behind, 
giving  rise  to  the  term  trigonocephalus. 

Peterson  regards  all  indices  between  seventy  and  ninety 
as  within  normal  hmits. 

Deformities  of  the  Palate.— The  Normal  Heart  Palate 
is  large  and  wide  and  moderately  arched.  Whereas  the 
palate  of  the  degenerate  is  usually  high  and  narrow. 

Peterson  describes  the  following  varieties  : — 

1.  The  Palate  with  Gothic  Arch.  Tliis  may  have  a  high  or 
low  pitch  and  may  be  short  or  long. 

2.  The  Palate  with  Horse-shoe  Arch.  Here  the  alveolus 
projects  into  the  cavity  of  the  mouth. 


GENERAL  SYMPTOMATOLOGY  93 

3.  The  Dome-shaped  Palate.  This  may  be  high  or  low,  and 
is  often  combined  with  asymmetry, 

4.  The  Flat-roofed  Palate.  This  includes  such  palates  as 
are  nearly  horizontal  in  outline,  as  well  as  those  with  inclined- 
roof  size  to  flattened  gable. 

5.  The  Hip-roofed  Palate.  In  this  the  anterior-posterior 
arch  is  greatly  accentuated. 

6.  The  asymmetrical  Palate.  This  is  usually  associated 
with  asymmetry  of  the  face  and  skull. 

7.  The  Torus  Palatinus  Palate.  In  this  there  is  a  projecting 
arch  or  swelling  below  the  palatine  suture. 

Deformities  o£  the  Limbs. — Although  these  do  not  all 
belong  to  the  stigmata  of  degeneration,  nevertheless  there  are 
some  which  must  be  considered  to  come  under  this  heading, 
e.g.  the  supernumerary  fingers  or  toes,  missing  fingers  or 
toes,  or  fusion  of  fingers  or  toes,  or  in  the  abnormally  short 
or  long  hmbs. 

Deformities  of  the  Body. — In  this  class  we  may  place 
dwarf  or  giant  growth. 

Disorders  of  Speech. — Stuttering  and  stanimering  are  com- 
monly found  in  the  relatives  of  the  insane,  but  not  so 
frequently  in  those  who  are  actually  of  unsound  mind.  The 
speech  may  be  incessant,  rapid,  and  incoherent,  or  it  may  be 
slow  and  laboured.  By  incoherence  is  meant  an  apparent 
want  of  connection  in  the  sequence  of  language.  In  other 
words,  it  is  an  inabihty  on  the  part  of  the  hearer  to  foUow 
the  thoughts  of  the  speaker.  There  is  a  difference  between 
wandering  conversation  and  true  incoherence,  for  in  the 
former,  notwithstanding  that  the  speaker  strays  from  subject 
to  subject,  his  thoughts  can  be  followed.  A  patient  once 
said  to  the  writer,  '  Maternal,  paternal,  infernal,  Dante.'  In 
this  case  his  thoughts  could  be  easily  followed,  as  the  first 
three  words  rhymed  and  the  last  was  an  association  of  ideas. 
The  mania  has  an  accelerated  flow  of  ideas,  while  the  thoughts 
of  the  melancholiac  are  slow  and  laboured. 

Mutism  is  present  in  a  certain  number  of  the  insane,  and 
may  be  due  to  the  absence  of  ideas  or  the  result  of  a  delusion. 
It  is  a  prominent  symptom  in  catatonia  and  other  stuporous 
states  and  is  present,  of  course,  in  the  congenitally  deaf.  Hesi- 
tancy and  slurring  of  speech  are  defects  which  may  indicate 


94  PSYCHOLOGICAL  MEDICINE 

serious  cerebral  disease.  Tremulousness  in  articulation  occurs 
in  the  exhaustion  psychoses  and  may  be  toxic  in  origin,  but 
it  is  a  symptom  which  may  also  point  to  organic  disease.  These 
symptoms  will  be  more  fully  considered  when  dealing  with 
general  paralj^sis.  Aphasia  of  all  kinds  is  met  with  in  the 
insane.  Sudden  and  transient  aphasia  is  very  suggestive  of 
general  paralysis. 

There  is  an  interesting  variety  of  speech,  met  with  in  cata- 
tonia and  some  other  types  of  mental  disorder,  known  as 
Verbigeration.  This  is  a  monotonous  repeating  of  words 
or  phrases.  In  conclusion,  it  may  be  mentioned  that  in  con- 
versation many  of  the  insane  repeat  the  question  put  to  them 
(echolalia)  ;  this  is  often  done  in  an  automatic  manner  and  as 
a  means  of  gaining  time  and  is  the  result  of  slow  ideation. 

Insomnia. — Sleeplessness  plays  such  a  very  important  part 
both  as  a  cause  and  symptom  of  mental  disorder  that  a  short 
chapter  has  been  devoted  to  its  study. 

Temperature. — The  temperature  of  the  body  in  the  insane 
varies  in  the  different  forms  of  mental  disorder,  but,  broadly 
speaking,  it  is  not  commonly  raised  in  mental  disease.  It  is 
imjDortant  to  make  a  habit  of  taking  the  temperature  of  these 
patients,  as  fever  is  frequently  the  first  indication  that  we 
may  have  that  the  patient  is  physically  ill.  Insane  persons 
do  not,  as  a  rule,  complain  of  subjective  sensations,  therefore 
in  treating  them  it  is  ever  necessary  to  be  observant.  For 
instance,  in  general  paralysis,  fever  not  infrequently  precedes 
'  seizures,'  and  in  many  forms  of  mental  disorder  it  connotes 
some  lung  complication  or  other  bodily  ailment.  Subnormal 
temperatures  are  usually  found  in  stuporous  states  and  in 
melancholia,  and  raise  temperatures  in  acute  delirious  states 
and  in  some  cases  of  puerperal  insanity.  There  may  be 
hyperpyrexia  in  conditions  such  as  status  epilepticus.  To 
sum  up,  fever  in  the  insane  generally  indicates  some  physical 
disease  in  the  same  way  as  it  does  in  the  sane. 

Reflexes,  Disorder  of. — The  superficial  reflexes  are  not  con- 
sidered to  be  very  important  factors  in  insanity.  They  are  use- 
ful in  the  diagnosis  of  hysterical  conditions,  as  the  plantar 
reflexes  are  usually  lost.  The  deeper  reflexes  are  affected  in 
many  forms  of  mental  disorder  ;  they  may  be  exaggerated, 
diminished,  or  lost.     The  knee-jerks  are  often  very  exaggerated 


GENERAL  SYMPTOMATOLOGY  95 

in  states  of  excitement  or  extreme  exhaustion.  Too  much 
weight  must  not  be  attached  to  the  condition,  but,  on  the  other 
hand,  they  are  common  in  general  paralysis.  Loss  of  knee- 
jerk  is  a  symptom  of  far  greater  importance,  as  it  frequently 
points  to  a  tabetic  form  of  general  paralysis.  The  physician 
must,  however,  bear  in  mind  that  it  may  be  due  to  peripheral 
neuritis.  The  changes  in  the  pupillary  reflexes  will  be  described 
in  the  chapter  on  General  Paralysis. 

Expression. — The  facial  expression  is  not  a  very  reliable 
indicator  of  the  emotions  in  the  highest  and  lowest  mental 
states,  for  in  the  highest  the  emotions  can  be  concealed,  and 
in  the  lowest  there  is  a  general  lack  of  expression.  Still, 
facial  expression  is  probably  a  truer  index  of  action  and  thought 
in  the  insane  than  in  the  sane.  There  are  certain  points  to  be 
noticed  in  examining  the  face  and  expression.  The  face  may 
appear  lengthened  and  toneless,  the  result  of  general  muscular 
relaxation ;  this  is  commonly  seen  in  melancholia  and  some 
cases  of  general  paralysis.  Terror  and  anxiety  are  shown  by 
the  facial  muscles,  the  emotional  tremors  being  caused  by 
strong  and  intermittent  nerve  currents  transmitted  to  the 
various  muscles.  Pain,  to  a  great  extent,  is  shown  in  the 
lower  part  of  the  face  ;  this  is  especially  the  case  with  visceral 
pain.  Mental  stress  is  usually  indicated  by  over-tone  of  the 
corrugator  supercilii,  which  causes  knitting  of  the  eyebrows. 
Twitching  of  the  supra-orbital  muscles  is  said  to  be  common  in 
forms  of  mental  disorder  due  to  alcohol.  I 

It  is  important  to  note  the  shape  and  size  of  the  head,  whether 
it  is  symmetrical,  or  whether  there  is  lack  of  development  on 
one  side,  as  is  seen  in  some  cases  of  traumatic  idiocy.  A  head 
with  a  circumference  of  less  than  seventeen  inches  is  incom- 
patible with  intellect.  Note  also  the  eyes,  whether  there  is 
any  drooping  of  eyelids  ;  whether  the  eyes  work  together 
or  the  eyeballs  are  prominent.  Exophthalmos  is  a  common 
symptom  in  some  maniacal  patients,  and  is  probably  due  to 
congestion  of  the  venous  circulation  at  the  back  of  the  orbit. 
The  size  and  various  reactions  of  the  pupils  should  be  exam- 
ined, mydriasis  being  commonly  found  in  nervous  and  fatigued 
persons.  Note  the  movements  of  the  eyeballs  in  their  sockets 
as  distinguished  from  the  various  movements  of  the  head,  as 
the  former  indicate  a  higher  state  of  evolution  than  the  latter. 


96  PSYCH0L0C4ICAL  MEDICINE 

An  infant  usually  turns  its  head  when  its  attention  is  attracted 
by  a  sound,  the  independent  movement  of  the  eyeballs  being 
of  later  development  and  sometimes  never  acquired.  Observe 
also  the  quickness  of  expression  and  the  rapidity  of  reaction 
to  stimuH,  and  further  observe  whether  the  two  sides  of  the 
face  act  together  and  to  an  equal  extent.  The  presence  or 
absence  of  hair  on  the  face  is  a  point  worthy  of  attention,  for 
it  must  be  borne  in  mind  that  degeneracy  in  the  male  may  be 
shown  by  absence  of  the  customary  hair  on  the  face,  whereas 
a  female  degenerate  is  often  hairy. 

Posture. — We  are  ever  moving  our  position,  and  every 
posture  is  temporary  and  may  be  looked  upon  as  a  balance  of 
muscular  action.  Warner  i  describes  four  principal  postures 
of  the  head  :  '  (a)  Flexion,  (b)  Extension,  (c)  Kotation  to 
one  or  other  side  in  a  horizontal  plane,  the  head  remaining 
erect,  but  the  face  being  turned  to  the  right  or*left.  {d)  In- 
cHnation  to  one  or  other  side,  lowering  one  ear  so  that  the 
two  do  not  remain  on  the  same  level.' 

Flexion  of  the  head  and  a  general  flexion  of  the  body  are 
seen  in  most  cases  of  melanchoha  and  in  certain  forms  of 
stupor.  Extension  of  the  head  may  be  due  to  spinal  irritation 
or  merely  the  result  of  a  delusion.  Eotation  usually  suggests 
an  hallucinatory  condition.  Persons  may  throw  themselves 
into  positions  of  prayer  or  other  ecstatic  postures.  The  reader 
need  not  be  detained  longer  on  this  subject,  except  to  remind 
him  that  much  may  be  leamt  by  observing  the  posture  of 
a  patient.  The  exalted  man  will  appear  proud  and  self- 
complacent  ;  the  depressed  man  flexed  and  drooping  ;  the 
persecuted  man  suspicious  and  anxious. 

Handwriting. — The  handwriting,  being  the  production  of 
highly  developed  and  co-ordinate  muscular  movements,  is  often 
of  great  diagnostic  value  in  the  study  of  disease.  Hand- 
writing is  of  comparatively  late  development,  and  therefore  is 
early  affected  in  every  form  of  nervous  disorder.  Even  with 
fatigue  the  clearness  and  character  of  the  writing  are  found  to 
be  altered.  In  studying  handwriting  in  its  more  highly 
developed  forms,  it  will  be  observed  that  there  is  a  great 
difference  between  the  up-  and  the  down-strokes,  for  the  latter 
are  bolder  and  stronger  and  show  greater  weight  of  the  hand 
^  '  Posture,'  in  Tuke's  Dictionary  of  Psychological  Medicine. 


GENERAL  SYMPTOMATOLOGY  97 

on  the  pen.  With  dissolution  this  difference  between  up-  and 
down-strokes  disappears,  and  every  stroke  will  be  heavy.  The 
pressure  of  the  pen  on  the  paper  is  of  interest,  for  a  child 
learning  to  write  cannot  even  use  a  pen  without  covering 
itself  and  the  paper  with  ink,  and  owing  to  the  weight  of  the 
child's  hand  it  is  necessary  for  a  pencil  to  be  used.  So  again 
with  increasing  dissolution  the  writing  will  once  more  be 
found  to  be  blotty  and  untidy,  and  the  day  comes  when  a 
pencil  alone  can  be  used.  In  the  early  stages  of  any  nervous 
disorder  the  up-strokes  of  writing  will  be  observed  to  be  shaky, 
indicating  tremor  of  muscles  when  Hghtly  stimulated.  With 
increasing  age  a  general  shakiness  becomes  very  evident, 
though,  as  a  rule,  the  character  of  the  writing  is  not 
markedly  affected.  Tremulousness  is  also  noticeable  in  the 
handwriting  of  patients  convalescing  from  any  serious  illness. 
A  keen  observer  can  glean  a  great  deal  as  to  the  health  of  a 
relative  or  friend  by  noting  his  handwriting.  If  the  corre- 
spondent is  weary  and  tired,  the  handwriting  shows  irritability 
and  uncertainty,  and  further  it  is  usually  smaller  and  more 
cramped,  as  is  the  case  in  the  writing  of  the  aged. 

There  are  several  other  points  to  be  observed  in  dealing 
with  the  handwriting  of  the  insane.  Some  patients  write 
slowly  and  with  great  effort,  either  from  difficulty  in  thought 
or  effort  in  the  production  of  the  various  letters.  If  the  latter 
is  the  case,  the  letters  will  usually  be  found  to  be  separate  and 
not  run  together.  In  some  forms  of  mental  disorder,  and  in 
general  paralysis,  there  is  a  tendency  to  drop  out  letters  or 
syllables,  showing  constant  irritability  and  failure  of  attention. 
On  the  other  hand,  words  may  be  reduplicated.  Some  patients 
write  an  enormous  amount,  either  of  prose  or  poetry,  and  the 
correspondence  of  these  individuals  is  frequently  very  large. 

Further,  much  can  be  learned  as  to  the  mental  state  of  a 
person  by  studying  the  contents  of  the  letters  he  writes.  The 
melanchohac's  notes  are  filled  with  gloomy  thoughts  about  the 
present  and  fears  for  the  future ;  the  hypochondriac  fills  his 
letters  with  descriptions  regarding  his  bodily  health ;  the 
exalted  man  with  grandiose  ideas  and  extravagant  schemes. 
The  moral  pervert  may  spend  his  time  in  writing  libellous 
post-cards :  this  symptom  of  mental  disorder  is  rather  more 
common  in  women.     Suspicions  and  delusions  of  persecution 

7 


98  PSYCHOLOGICAL  MEDICINE 

may  first  shoT\-  themselves  in  the  contents  of  a  letter.  Before 
leaving  the  subject  of  handwriting,  an  interesting  variety 
kno^Ti  as  mii'ror--^Titing  must  be  named.  It  is  found  in  certain 
degenerates  and  may  be  a  symptom  in  some  persons  suffering 
from  mental  disorder.  Mirror-^Titing  is  usually  effected  by 
the  left  hand  and  is  written  from  left  to  right  and  can  only 
be  read  by  means  of  a  looking-glass,  or  if  the  paper  on  which 
it  is  written  is  very  thin,  by  holding  it  up  to  a  strong  Hght. 

In  reading  the  following  accounts  of  the  various  forms  of 
mental  disorder,  it  will  be  well  for  the  student  from  time  to 
time  to  refer  back  to  this  chapter  on  General  Symptomatology, 
so  that  he  may  keep  clearly  before  him  the  exact  significance 
of  the  symptoms  recorded. 


99 


CHAPTEE  VI 

MANIA 

Excitement  in  its  various  degrees  is  much  more  readily 
recognised  than  depression,  and  it  is  easier  to  say  when  the 
hne  which  divides  sanity  from  insanity  has  been  crossed,  for 
the  reasoning  power  is,  as  a  rule,  lost  quite  early.  On  account 
■of  this,  acute  mania  is  one  of  the  few  forms  of  insanity  recog- 
nised by  the  lay  mind  ;  for  if  a  man  is  noisy,  destructive,  or 
violent,  it  does  not  require  a  physician  to  diagnose  that  such 
a  person  is  insane.  On  the  other  hand,  it  is  not  enough  to 
say  that  a  patient  is  suffering  from  mania  ;  the  question  further 
arises  as  to  what  is  the  cause  of  this  excitement.  Excite- 
ment, Uke  depression,  may  be  the  whole  visible  evidence  of  the 
condition  ;  or  it  may,  on  the  other  hand,  be  associated  with 
other  symptoms  which  coimote  gross  brain  disease,  or  the 
grouping  of  symptoms  may  be  such  as  to  indicate  a  disorder 
such  as  maniacal-depressive  insanity. 

jffiJtiology.- — Excitement  may  occur  at  any  period  of  hfe,  but 
is  more  common  in  the  earlier  epochs.  It  is  almost  physio- 
logical in  its  mildest  forms  during  childhood,  but  as  evolution 
takes  place  the  emotions  become  more  and  more  controlled. 
Again,  with  senihty  the  highest  levels  may  degenerate 
first,  with  the  result  that  the  power  of  inhibition  is  lessened 
and  outbursts  of  excitement  or  other  symptoms,  due  to  loss  of 
control,  ensue.  Mania  is  by  no  means  so  commonly  met  with 
as  depression,  but  in  many  ways  it  is  a  more  serious  disorder. 
It  must  be  borne  in  mind  that  delirium  is  temporary  mania, 
and  in  certain  neurotic  subjects  it  may  pass  on  to  a  definite 
acute  attack  of  excitement.  Sex  is  not  an  important  factor, 
but  women  are  somewhat  more  liable  to  attacks  of  mania  than 
men.  A  definite  neurotic  inheritance  is  found  in  a  fairly 
large   proportion   of    cases,    and    especially   in   patients   who 


100  PSYCHOLOGICAL  MEDICINE 

break  down  early  in  life.  The  instability  may  have  shown 
itself  previously  by  too  rapid  or  too  slow  evolution,  or  a  ten- 
dency to  night  terrors  or  other  psychoses.  Phthisis  or  other 
exhaustive  types  of  disease  may  be  found  in  the  family  history. 
Exciting  and  anxious  forms  of  occupation  predispose  to  mania 
in  some  persons,  and  this  fact  should  be  remembered  when 
advising  concerning  the  education  of  a  neurotic  youth.  Ill- 
health  and  starvation  are  potent  factors  in  the  production  of 
mania. 

There  are  certain  toxic  conditions  which  may  in  predisposed 
persons  tend  to  produce  excitement ;  more  especially  may  be 
instanced  alcohohsm,  plumbism,  uraemia,  and  drugs — such  as 
belladonna.  Mania  may  arise  from  a  defective  blood-supply 
to  the  brain,  or  from  a  vitiated  condition  of  the  blood.  During 
the  febrile  stage  of  specific  fevers  excitement  may  develop — 
in  short,  anything  which  produces  delirium  may  engender 
acute  mania.  Epileptic  furor  is  a  very  violent  form  of  excite- 
ment which  sometimes  follows  a  fit  of  epilepsy.  In  the  female, 
childbirth  may  be  followed  by  an  attack  of  mania  of  the 
exhaustive  type  ;  and,  finally,  sleeplessness  is  also  a  factor 
which  must  not  be  forgotten. 

Varieties. — There  are  several  types  of  mania  which  must 
be  recognised.  Attacks  of  mania  may  occur  periodically 
throughout  the  hves  of  some  people,  or  mania  and  melancholia 
may  alternate  with  periods  of  health.  The  terms  'periodical, 
recurrent,  and  circular  insanity  are  used  by  some  writers  to 
denote  these  cases,  but  Kraepelin  has  pointed  out  that  where 
mania  and  melanchoha  occur,  under  such  conditions,  the 
symptoms  are  not  accidental,  but  should  more  properly  be 
considered  as  phases  of  one  disease.  He  describes  these  cases 
under  the  head  of  maniacal-degressive  insanity,  for,  as  he  rightly 
shows,  the  disorder  follows  a  definite  course,  which  is  usually 
repeated  in  each  succeeding  attack.  Kraepelin  recognises 
three  forms  of  maniacal-depressive  insanity,  viz.  the  maniacal, 
the  depressive,  and  the  mixed.  Older  writers  would  describe 
these  as  recurrent  mania,  recurrent  melancholia,  and  folie 
circulaire. 

As  mania  may  exist  apart  from  these  periodic  or  circular 
conditions,  it  would  be  more  convenient  to  describe  the  state 
under  the  following  heads  : — - 


MANIA  101 

1.  Simple  Mmiia,  in  which  there  are  usually  no  delusions 
or  hallucinations.  It  frequently  occurs  early  in  life  and  has 
a  tendency  to  recur  periodically  or  may  alternate  with  a 
phase  of  depression. 

2.  Acute  Mania. — Some  authorities  consider  this  to  be  a 
more  intense  form  of  simple  mania.  Others  make  a  distinction 
between  them.  This  disorder  may  appear  at  any  age  but  is 
more  common  in  adolescence  and  in  early  middle  life. 

3.  Recurre7it  Mania  (Maniacal-Depressive). — This  may  be 
either  simple  or  acute  mania  in  the  character  of  symptoms. 

4.  Chronic  Mania. — The  symptoms  in  this  condition  are 
very  similar  to  those  found  in  acute  mania,  though  there  is 
usually  greater  degeneracy  present. 

5.  Acute  Delirious  Mania. — At  one  time  this  was  considered 
a  separate  disorder  from  other  types  of  excitement,  but  in 
recent  years  the  evidence  seems  strongly  to  indicate  that  it 
is  merely  a  later  type  or  more  advanced  stage  of  acute  mania 
of  the  exhaustion  type. 

In  addition  to  these  varieties  of  mania,  the  student  must 
bear  in  mind  that  excitement  may  be  the  mental  state  of  a 
certain  proportion  of  persons  suffering  from  general  paralysis 
or  other  forms  of  organic  disease. 

Prodromata. — The  onset  may  be  gradual  or  sudden,  but  the 
former  is  more  common.  A  sudden  outburst  of  excitement 
may  occur  in  recurrent  cases  or  may  be  secondary  to  an 
epileptic  seizure  or  due  to  drugs — such  as  alcohol  or  bella- 
donna. As  a  rule  there  is  a  period  of  malaise  or  depression, 
during  which  time  the  patient  is  sleepless  and  loses  weight ; 
this  may  last  for  some  days  or  weeks  before  the  over-activity 
and  restlessness  of  mania  appear.  As  the  excitement  develops, 
the  patient  talks  incessantly  ;  he  rises  very  early  in  the  morning 
and  retires  late  to  bed.  His  conduct  becomes  as  erratic  and 
uncertain  as  his  conversation.  He  dresses  in  an  extravagant 
fashion  and  spends  money  rapidly.  He  is  irritable  and  refuses 
to  be  controlled.  Loss  of  control  is  the  prominent  feature  of 
both  his  actions  and  his  conversation.  The  power  of  attention 
fails  rapidly,  and  he  becomes  unable  to  hold  a  connected 
conversation  or  carry  out  any  of  his  usual  duties.  Judgment 
and  reasoning  are  soon  affected,  and  it  is  on  this  account  that 


102  PSYCHOLOGICAL  MEDICINE 

there  is  but  little  difficulty  in  deciding  when  the  bounds  of 
sanity  have  been  passed. 

Mental  Symptoms. — (1)  Simple  Mania. — This  is  the  mildest 
type  of  mania.  The  patient  has  an  exaggerated  sense  of  well- 
being.  He  is  buoyant  and  in  the  best  of  spirits.  He  is  ex- 
travagant in  his  dress  and  squanders  money.  He  may  be  very 
exalted  as  regards  both  his  wealth  and  his  social  rank.  In 
this  connection  a  word  of  warning  is  needed.  These  cases  are 
frequently  diagnosed  as  general  paralytics  from  their  mental 
symptoms  alone.  Once  again  let  emphasis  be  laid  on  the 
point  that  general  paralysis  is  a  physical  disease  and  may  be 
accompanied  by  any  form  of  mental  disorder.  Exaltation 
per  se  does  not  connote  general  paralysis.  The  patient  with 
simple  mania  is  garrulous  and  talkative  and  much  that  he  says 
is  unconventional  and  bizarre.  He  is  exceedingly  quarrelsome 
and  often  throws  up  his  occupation  with  the  intention  of 
going  on  the  stage  or  following  some  other  pursuit  which  is 
more  suited  to  his  exceptional  mental  powers.  He  usually 
gets  engaged  to  be  married  to  several  young  women  in  quick 
succession,  as  his  ideas  of  marriage  are  ever  changing.  He 
will  generally  be  found  to  be  boastful ;  loss  of  control  stamps 
his  every  thought  and  action. 

The  memory  is  not  markedly  affected,  but  the  attention 
is  easily  distracted.  The  emotions  constantly  vary ;  more 
commonly  the  patient  is  exuberant  in  spirits,  but  he  is  always 
liable  to  outbursts  of  passion,  and  sometimes  will  lapse  into 
tears.  He  may  change  his  creed,  and  from  being  an  indifferent 
Protestant  he  may  become  a  devout  Eomanist.  As  a  rule 
there  are  no  hallucinations,  and  delusions,  if  any,  are  tem- 
porary and  fleeting.  Patients  suffering  from  simple  mania 
are  generally  sleepless,  waking,  as  a  rule,  early  in  the  morning. 
There  is  a  tendency  to  indulge  in  sexual  excitements.  The 
appetite  is  capricious  ;  the  patient  may  at  different  times  eat 
largely  or  go  without  food  for  many  hours.  The  physical 
health  is  fairly  good,  though  it  may  fail  if  the  illness  goes  on 
for  some  months.  Patients  of  the  class  are  by  no  means 
always  certifiable  and  many  of  them  can  be  treated  by  rest 
at  home.  Others  are  so  difficult  to  control  that  asylum 
treatment  is  absolutely  necessary. 

2.  Acute   Mania. — In  this   disorder   both  the   mental   and 


MANIA  103 

physical  symptoms  are  more  marked  than  in  simple  mania. 
There  is  greater  loss  of  control  in  speech  and  action.  These 
patients  are  constantly  on  the  move  and  never  rest ;  they 
may  sing,  dance,  laugh,  or  shout  continuously.  Speech  is  very 
incoherent,  and,  though  the  attention  may  be  attracted  for 
a  moment,  the  thoughts  will  soon  wander.  Patients  of  this 
class  are  very  quick  both  in  sight  and  hearing,  and  their  senses 
are  hypersensitive  in  their  acuteness.  Perception  is  normal. 
They  are  careless  of  the  presence  of  others  and  for  the  time 
being  seem  to  live  in  a  world  of  their  own.  They  are 
frequently  considered  brilliant  in  their  conversation;  this  is 
not  actually  the  case,  for  when  analysed  this  seeming  brilliancy 
will  be  found  in  large  measure  to  be  due  to  the  unconventional 
character  of  their  chatter ;  they  say  smart  things,  which 
s.trike  the  hearer  who  is  not  used  to  home  truths  and  person- 
alities as  amusing.  These  patients  are  often  more  entertaining 
when  ill  than  during  health,  for  through  loss  of  control  they 
will  make  remarks  in  illness  which  they  would  in  health  perhaps 
think  but  forbear  to  utter.  Association  of  ideas  is  more  active 
than  in  normal  conditions,  and  it  is  for  this  reason  that  the 
patient  is  incoherent,  as  he  is  unable  to  find  words  quickly 
enough  to  express  his  thoughts.     (Flight  of  Ideas.) 

The  acute  maniac  may  rhyme,  or  his  ideas  may  be  sug- 
gested by  objects  round  about.  These  patients  are  usually 
very  impulsive  and  destructive  and  at  times  may  be  violent. 
They  are  often  considered  almost  superhuman  in  their  strength, 
but  in  reality  they  are  weaker  than  in  health.  They  appear 
to  be  strong,  for  they  have  singleness  of  purpose  and  use  all 
their  strength  in  one  direction,  and  in  this  way  they  differ 
from  the  sane  person,  as  the  latter  is  constantly  inhibiting 
his  actions.  For  example,  a  maniac  would  use  all  his  strength 
to  remove  an  annoying  person  from  his  room,  heedless  of 
whether  in  carrying  out  his  intention  he  either  damaged 
himself  or  his  persecutor.  Their  actions  are  in  keeping  with 
their  mental  state.  They  collect  all  manner  of  rubbish,  filling 
their  pockets  with  worthless  articles  after  the  manner  of 
schoolboys.  Young  women  tie  bits  of  string  round  their 
fingers  to  replace  any  rings  that  have  been  removed  and 
decorate  their  hair  with  ivy  and  flowers.  They  are  often 
irritable,    and    may    quickly    lose    their   temper    and    strike 


104  PSYCHOLOGICAL  MEDICINE 

and  may  accidentally  kill,  but  intentional  homicide  is 
rare. 

Usually  these  patients  are  happy  and  cheerful,  but  the 
emotions  may  undergo  a  sudden  change  and  the  tears  of  one 
moment  may  give  way  to  the  laughter  of  the  next.  It  is  by  no 
means  uncommon  to  iind  that  they  mistake  identity  and  will 
address  those  about  them  either  as  relatives  of  their  own  or 
as  celebrities  of  the  day.  Memory  is  fairly  good,  but  at  times 
uncertain.  It  is,  however,  remarkable  how  many  details  of 
his  illness  a  patient  of  this  type  will  remember  after  recovery. 
The  habits  vary  greatly,  according  to  the  severity  of  the 
attack.  Some  patients  are  very  degraded  and  will  eat  all 
manner  of  filth,  while  others  will  strip  off  their  clothing.  The 
sexual  instincts  are  exalted  and  give  rise  in  both  sexes  to 
immodest  actions  and  speech  and  at  times  to  shameless 
masturbation. 

Delusions  are  ever  changing  and  are  usually  exalted  in 
character  ;  the  maniac  may  adhere  to  a  delusion  for  some 
time,  but,  as  a  rule,  if  contradicted  he  will  abandon  his  belief 
or  replace  it  by  another.  Similarly  hallucinations  are  tem- 
porary and  fleeting.  Music  and  other  sounds  may  be  heard, 
or  faces  and  lights  may  float  across  the  room.  Auditory 
hallucmations  are  more  common  than  visual  sensory  disorders, 
except  in  cases  of  mania  due  to  some  drug-poisoning.  Sleep 
is  very  deficient  and  may  be  absent  for  weeks,  and  profound 
insomnia  is  very  characteristic  of  this  disorder.  In  the  severe 
forms  of  acute  mania  a  patient  will  spend  his  nights  and  his 
days  in  constant  movement  and  continual  laughter  and  speech. 
Such  patients  are  apt  to  wear  themselves  out,  and  some  die 
from  exhaustion.  Attempts  at  suicide  are  rare,  but  a  maniacal 
person  may  kill  himself  by  accident  in  trying  to  do  some  im- 
possible feat.  To  sum  up  :  all  maniacs  are  capricious  and  are 
swayed  by  their  constantly  changing  thoughts  and  ideas  ; 
continued  occupation  is  impossible,  and  employment  depends 
on  the  fancy  of  the  moment. 

8.  Recurrent  Mania  {Maniacal-Depressive).- — The  periodic 
or  recurrent  forms  of  mania  or  the  mixed  variety  of  Kraepelin's 
maniacal-depressive  insanity  usually  appear  during  the  earlier 
epochs  of  life.  The  excitement  varies  in  intensity,  and  the 
type  may  be  that  already  described  under  '  Simple  '  or  '  Acute 


MANIA  105 

Mania.'  In  many  instances  each  succeeding  attack  leaves  its 
effect  on  the  intellect  of  the  patient,  who  may  progressviely 
lose  the  capability  of  doing  work.  The  intervals  between 
the  attacks  vary  in  length,  but  the  tendency  is  for  them  to 
grow  shorter  as  age  advances.  The  attacks  frequently  begin 
with  a  period  of  depression  which  is  followed  by  a  period  of 
excitement,  and  this,  in  turn,  is  succeeded  by  a  stuporose  state 
which  some  authorities  have  named  '  Anergic-stupor.' 

4.  Chronic  Mania. — In  this  condition  the  symptoms  are 
usually  less  marked  than  in  acute  excitement,  otherwise  they 
are  very  much  the  same,  except  that  there  is  usually  some  mental 
enfeeblement  accompanying  it  and  the  memory  tends,  on  the 
whole,  to  fail,  though  at  times  one  may  observe  that  the  patient 
evinces  an  extraordinary  memory  in  certain  directions — such 
■as  names,  dates,  etc. 

5.  Acute  Delirious  Mania. — There  is  usually  an  insane 
inheritance  in  these  cases  and,  in  addition,  some  definite  exciting 
cause  which  may  be  either  physical  or  mental.  It  is  more 
commonly  found  in  the  exhaustion  type  of  excitement,  though 
it  may  be  a  later  stage  of  ordinary  acute  mania.  The  symptoms 
closely  resemble  those  of  the  dehrium  observed  in  acute  specific 
fevers.  Insomnia  is  profound,  restlessness  is  intense.  Speech 
is  very  incoherent  and  the  patient  may  become  noisy.  It  is 
very  difficult  to  attract  his  attention,  even  for  a  moment,  and 
the  sufferer  wdll  sit  up  in  bed,  constantly  chattering  to  himself 
and  swaying  about. 

Memory  is  almost  entirely  obliterated  for  the  time  being. 
Hallucinations,  especially  of  sight,  are  very  common  ;  delu- 
sions of  all  kinds  occur,  but  they  are  very  fleeting  and  con- 
stantly changing.  The  face  is  flushed,  and  th3  pulse  is  very 
frequent  and  low-tensioned.  Food  is  refused  and  has  to  be 
given  artificially  by  means  of  an  oesophageal  or  nasal  tube. 
The  tongue  is  furred,  and  sordes  form  on  the  hps  and  mouth. 
The  temperature  is  nearly  always  raised  two  or  three  degrees, 
and  in  this  it  differs  from  acute  mania.  The  urine  is  scanty 
and  high-coloured  ;  the  excretions  are  passed  under  the 
patient.  He  rapidly  develops  a  typhoid  condition,  lying  in 
bed  in  a  state  of  low  muttering  dehrium.  He  differs  from 
the  sufferer  from  enteric  in  that  he  resists  all  attempts  at 
nursing.     Bed-sores  frequently  form  in  spite  of  every  care. 


106  PSYCHOLOGICAL  MEDICINE 

Physical  Ssnnptoms. — Physical  symptoms  differ  greatly 
according  to  the  severity  of  the  attack.  In  simple  mania 
they  are  slight  and,  except  for  some  loss  of  weight,  may 
not  be  well-marked.  On  the  other  hand,  in  the  more  severe 
types  of  mania,  the  plwsical  conditions  may  occasion  grave 
cause  for  anxiety. 

Gastro-Mtestinal  System. — The  tongue  is  usually  furred,  and 
there  may  be  sordes  about  the  hps  and  mouth.  There  is  an 
increase  of  the  hj^drochloric  acid  in  the  gastric  juice,  which  has 
been  found  to  be  more  toxic  than  normal.  The  appetite  is,  as 
a  rule,  bad,  but  the  maniacal  patient  is  very  capricious  in  the 
matter  of  food  ;  he  may  eat  one  meal  ravenously  and  refuse 
the  next  two  or  three.  It  is  often  necessary  to  feed  these 
cases  by  means  of  the  nasal  or  oesophageal  tube,  otherwise 
rapid  loss  of  weight  with  serious  results  may  ensue.  Con- 
stipation and  general  irregularity  of  bowel  action  are  common 
but  not  as  constant  as  in  melanchoHa. 

Circulatory  System. — The  pulse  is  frequent  and  low-tensioned. 
The  frequency  may  reach  as  high  as  140-150  beats  a  minute. 

Bespiratory  System. — The  rate  of  breathing  is  not  materially 
increased  ;  the  usual  ratio  between  heart-beat  and  respiration 
is  lost. 

Genito-Urinary  System. — The  quantity  of  urine  secreted  in 
some  cases  is  greater  than  normal,  while  in  others  it  is  less. 
The  menstrual  functions  in  women  are  always  disordered. 
The  catamenia  may  be  scanty  and  irregular,  or  entirely  absent, 
throughout  the  attack  ;  on  the  other  hand,  there  may  be 
menorrhagia  or  metrorrhagia.  Some  patients  have  exacerba- 
tions of  excitement  either  before  or  immediately  after  the 
catamenia,  wliile  for  a  fortnight  between  the  periods  they  may 
to  all  appearances  be  well. 

Nervous  System. — Except  for  a  general  hypersesthesia  of 
the  special  senses,  the  nervous  system  does  not  exhibit  any 
special  symptoms.  Maniacal  persons  will  constantly  strip 
off  their  clothing,  but  it  is  not  clear  whether  this  is  due 
to  altered  bodily  sensations.  After  an  attack  of  mania  it  is 
common  to  find  a  temporary  general  anaesthesia  which  passes 
off  rapidly. 

Stoddart  has  drawn  attention   to   the  striking   differences 


MANIA  107 

in  the  movements  of  the  maniac  as  compared  with  the  melan- 
chohac.  The  movements  of  the  maniacal  patient  take  place 
for  the  most  part  at  the  large  proximal  joints,  whereas  in 
melancholia  these  are  weak  or  rigid.  The  body  weight  usually 
falls  rapidly,  and  there  is  general  emaciation.  The  skin  and 
appendages  suffer  from  nutritional  changes.  Small  pustules 
may  develop  ;  the  nails  are  friable,  furrowed,  and  contain 
opaque  patches  ;  the  hair  is  dry  and  brittle — ^it  loses  its  lustre 
and  sometimes  falls  out.  The  patient  may  become  very 
anaemic  as  the  illness  proceeds.  The  temperature  is  usually 
about  normal,  except  in  cases  of  acute  delirious  mania,  when 
it  is  often  raised.  There  is  a  tendency  to  salivation  in  some 
cases,  but  this  is  not  a  constant  symptom.  Stoddart  found 
that  the  maniac  reacted  readily  to  pilocarpine  and  jaborandi. 
Sleep  is  very  bad  and  its  continued  absence  may  lead  to  very 
serious  consequences.  Maniacal  patients  not  uncommonly 
develop  some  intercurrent  affection,  especially  disorders  of  the 
respiratory  system. 

Course. — Mania  may  run  a  very  rapid  course,  the  acute 
symptoms  passing  off  within  a  few  days.  Mental  excitement 
of  this  type  is  often  spoken  of  as  mania  transitoria  ;  it  occurs 
in  certain  alcoholic  and  epileptical  cases  and  is  seen  also  at 
the  time  of  labour  in  some  very  neurotic  subjects.  It  is  a 
violent  attack  of  excitement  that  passes  off  as  rapidly  as  it 
appears.  Eecovery  usually  takes  place  more  slowly — com- 
monly after  eight  or  nine  months.  The  disease  reaches  its 
height  after  five  to  ten  weeks  ;  after  which  the  physical  health 
tends  to  show  signs  of  improvement.  Food  which  has  pre- 
viously been  refused  is  now  taken,  the  appetite  being  abnor- 
mally large.  The  mental  excitement  fluctuates  from  day  to 
day,  but  shows  an  improving  tendency.  The  hair  and  the 
general  appearance  of  the  patient  become  more  tidy.  Sleep 
improves,  but  slowly.  There  is  a  greater  tendency  to  help  in 
the  domestic  work  of  the  wards  of  the  hospital,  and  the  rest- 
lessness is  less  marked.  Some  patients  become  quarrelsome 
and  fault-finding  as  they  progress  towards  health,  and  are  a 
sore  trial  to  nurses  and  those  in  authority.  They  make  all 
kinds  of  false  accusations  of  rough  treatment,  assaults,  and 
the  like,  which,  on  careful  inquiry,  prove  to  be  baseless.     More 


108  PSYCHOLOGICAL  MEDICINE 

commonly,  patients  who  are  recovering  from  mania  pass  into 
a  confused  and  apathetic  condition,  in  which  they  take  httle 
or  no  interest  in  their  smToundings  and  rarely  occupy  them- 
selves. These  patients,  as  a  rule,  steadily  improve  in  their 
phj^sical  health.  The  condition  is  not  one  of  true  depression, 
but  is  rather  one  of  general  fatigue  resulting  from  the  intense 
excitement  through  which  they  have  passed.  It  resembles 
the  feeling  of  malaise  and  apathy  experienced  by  some  persons 
after  several  evenings  of  dancing  and  social  excitements.  In 
other  cases  this  confused  apathetic  condition  passes  on  to  a 
more  definite  state  of  stupor  and  is  called  by  some  authorities 
post-maniacal  stupor  and  by  others  anergic  stupor.  But 
it  will  be  more  convenient  to  describe  this  condition  in  a 
subsequent  section.  After  passing  through  these  various 
stages,  recovery  may  take  place.  On  the  other  hand,  a  patient 
may  reach  a  certain  point  towards  recovery,  yet  the  final 
recovery  does  not  take  place  till  some  months  later. 

Persons  in  asylums  and  under  care,  as  a  rule,  appear  to  be 
much  better  than  they  really  are,  and  to  allow  them  too  early 
freedom  has  a  bad  effect  and  is  apt  to  cause  a  relapse.  Many 
patients,  who  have  apparently  recovered,  are  found  to  be 
defective  in  one  or  more  respects.  Savage  aptly  describes  the 
condition  as  the  scar  that  is  left  after  the  illness  has  passed  off. 
The  scar  may  show  itself  in  many  ways — as,  for  example,  in 
mental  or  moral  defects.  A  man,  previously  energetic  and 
keen,  may  become  idle  or  indolent.  He  may  develop  habits 
of  drinking  or  gaming,  which  show  a  lack  of  control.  From 
being  jDlacid  and  easy-going,  he  may  become  irritable  and 
passionate.  There  may  be  either  complete  or  partial  recovery. 
Recovery  may  be  partial,  but  sufficiently  well  marked  to 
render  the  patient  capable  of  earning  his  own  living.  On  the 
other  hand,  a  number  of  cases  never  recover,  but  steadily 
pass  into  a  weak-minded  condition. 

All  insanities  tend  to  dementia,  but  mania  more  strongly 
than  others.  The  patient  may  improve  physically  and  his 
weight  increase  ;  sleep  may  retm-n  ;  and  the  bodily  functions, 
which  were  formerly  deranged,  may  be  normally  performed. 
Nevertheless,  with  all  this  improvement  he  may  remain  weak- 
minded,  noisy,  and  destructive.  The  term  '  Secondary  De- 
mentia '  is  frequently  used  to  describe  this  condition.     Death 


MANIA  109 

supervenes  in  about  five  per  cent,  of  the  cases.  The  cause  of 
death  may  be  some  intercurrent  disease,  but  exhaustion  alone 
is  by  no  means  infrequent,  for  there  is  httle  doubt  that  acute 
excitement  leads  to  serious  defects  in  the  nutrition  of  the  brain. 
An  autopsy  on  the  body  of  a  patient  who  has  died  from  acute 
mania  reveals  no  signs  of  organic  disease.  In  some  of  these 
cases  the  conclusion  that  death  has  resulted  from  exhaustion 
is  irresistible  ;  and  this  conclusion  is  supported  both  by  the 
clinical  and  post-mortem  evidences. 

Diagnosis.^ — Excitement  itself  is  not  difficult  to  diagnose, 
but  care  must  be  taken  not  to  confuse  the  delirium  of  some 
fevers  with  acute  mania.  Carelessness  in  this  respect  has  led 
to  patients  suffering  from  pneumonia  or  some  specific  fever 
being  sent  to  an  asylum  as  insane.  Delirium  is  temporary 
insanity,  but  it  is  not  proper  or  usual  for  ordinary  delirious 
patients  to  be  certified  as  of  unsound  mind.  A  raised  tempera- 
ture should  always  put  a  physician  on  his  guard,  as  fever  is 
rare  in  mania  except  in  its  more  severe  forms.  Examine  the 
patient  carefully  for  any  rash.  UraBmia  has  also  been  mistaken 
for  mania.  Try  and  determine  whether  the  excitement  is 
purely  functional  in  character,  or  whether  it  is  the  mental 
aspect  of  some  organic  disease.  Never  forget  to  look  for 
symptoms  of  general  paralysis.  The  mental  excitement  of  the 
latter,  when  it  occurs,  is  usually  very  acute,  and  the  patient 
is  most  unreasoning  and  more  insane  than  is  the  case  with 
ordinary  mania. 

Alcohohc  conditions  are  at  times  difficult  to  differentiate 
from  simple  maniacal  states,  and  it  is  hard  at  times  to 
distinguish  delirium  tremens  from  acute  delirious  mania. 
The  temperature  is  raised  in  the  latter,  and  is  subnormal,  as 
a  rule,  in  delirium  tremens  ;  also  in  acute  delirious  mania 
the  patient  is  flushed,  while  in  the  alcoholic  deliiium  he  is 
pale  and  of  anaemic  appearance.  The  alcoholic  is  afraid  of  his 
hallucinations,  but  the  ordinary  maniacal  patient  shows  no 
such  fear.  Drug-poisoning  must  also  be  borne  in  mind  in 
making  a  diagnosis.  Epilepsy  and  seizures  should  also  be 
considered.  Hysterical  cases  at  times  are  difficult  to  diagnose, 
but  they  exhibit,  as  a  rule,  the  symptoms  common  to  hysteria 
and  will  be  fully  dealt  with  elsewhere.  Dementia  prsecox  may 
be  confused  with  mania,  but  patients  with  the  former  disorder 


110  PSYCHOLOGICAL  MEDICINE 

are  usually  more  childish.  The  history  will  assist  in  arriving 
at  a  proper  diagnosis  in  those  cases  of  paranoia  which  are 
accompanied  by  maniacal  outbursts. 

Prognosis. — The  immediate  prognosis  is  good  in  cases  of 
simple  mania,  but  the  ultimate  is  by  no  means  so  hopeful, 
recurrent  attacks  being  common.  In  acute  mania  the  outlook 
is  faii'ly  good,  so  long  as  the  general  physical  condition  remains 
satisfactory,  rapid  emaciation  pointing  to  an  unfavourable 
prognosis.  The  presence  of  auditory  hallucinations  makes  the 
outlook  more  grave.  The  same  is  true  of  marked  degeneracy, 
indicated  by  the  eating  of  filth  or  total  disregard  of  the 
calls  of  nature.  As  a  general  rule,  a  maniacal  outbreak  in  the 
early  epochs  of  life  indicates  that  there  wUl  be  subsequent 
attacks.  This  is  more  likely  to  be  the  case  if  there  is  definite 
cause  for  the  illness,  or  if  there  is  a  marked  nem'otic  inheritance. 
The  prognosis  is  bad  in  many  cases  of  acute  delirious  mania 
and  probably  only  careful  feeding  and  good  nursing  will  give  a 
patient  any  chance  of  recovery. 

Pathology  and  Morbid  Anatomy. — The  pathology  of  mania 
is  stUl  somewhat  obscm'e.  Eeference  is  made  to  change  in 
the  blood  in  mania,  in  the  chapter  on  General  Symptomatology. 
Delirium  is  usually  caused  by  infective  toxic  agents.  Micro- 
organisms have  been  found  in  the  blood  of  patients  with  acute 
delirious  mania,  but  most  of  these  organisms  appear  to  be  the 
common  pathogenic  bacteria  usually  found  with  suppuration. 
Bianchi  and  Piccinino  reported  that  they  had  found  a  special 
bacillus  in  the  blood  of  persons  suffering  from  acute  delirious 
mania,  and  on  this  ground  they  concluded  that  there  must  be  a 
special  form  of  delirium,  which  they  named  Acute  Bacillary 
Delirium. 

Auto-intoxication  from  the  gastro-intestinal  canal  is  a  theory 
which  continues  to  gain  support.  Marro  has  reported  several 
recoveries  from  the  treatment  of  washing  out  the  stomach  of  such 
patients  ;  this  is  a  very  strong  corroborative  evidence  that — 
at  any  rate,  in  some  cases  of  maniacal  excitement — absorption 
of  deleterious  matter  from  the  ahmentary  canal  may  give  rise 
to  mental  disorder.  The  question  of  altered  blood-supply  to 
the  brain  is  one  that  still  requires  further  investigation  ;  but 
a  confident  belief  may  be  entertained  that  it  plays  no  small 
part  m  the  production  of  mania.     In  support  of  this  view  the 


MANIA  111 

writer  has  known  an  attack  of  acute  mania  to  result  from  liga- 
ture of  the  internal  carotid  artery ;  again,  delirium  is  a  common 
sequel  to  starvation.  In  considering  the  bearing  that  changes 
of  the  blood-pressure  may  have  upon  mania,  it  may  be  usefully 
observed  that  mental  disorder  associated  with  aortic  disease  is 
almost  always  maniacal  in  character.  It  is  interesting,  too,  to 
note  that  even  the  ordmary  physiological  fall  of  blood-pressure, 
which  occurs  in  the  latter  part  of  the  day,  is  accompanied  by 
mild  excitement  when  compared  with  the  mental  state  of  the 
early  morning.  In  acute  dehrious  mania,  and  even  in  other 
forms  of  mania,  the  quantity  of  blood  in  the  system  is  found 
to  be  greatly  decreased,  and  infusion  of  a  saline  solution  leads 
to  a  rapid  and  marked  improvement  in  the  patient's  mental 
condition.  Whether  the  actual  disorder  is  the  result  of  altered 
blood-states  or  not,  it  is  most  probable  that  the  feeling  of 
well-heing,  so  commonly  experienced  in  states  of  mania,  is  due 
to  altered  blood-pressure.  The  morbid  changes  which  are 
found  in  the  brains  of  persons  dying  from  acute  mania  show, 
in  varying  degrees,  degeneration  of  the  neuron.  It  is  certain 
that  the  nerve-cells  ultimately  suffer  in  their  entirety,  but  in 
all  probabihty  the  condition  is  secondary  to  something  else. 

Treatment. — Many  points  regarding  the  treatment  of  mania 
win  be  found  in  the  special  chapter  on  Treatment ;  and  sugges- 
tions will  here  be  limited  to  those  matters  which  are  especially 
connected  with  mania.  The  physician  must  decide  where  he 
considers  it  best  for  the  patient  to  reside  during  his  iUness. 
The  milder  forms  of  excitement  seldom  come  under  treatment, 
as  the  symptoms  of  mania  are  not  usually  recognised  as  such, 
but  are  taken  rather  to  indicate  good  spirits  and  exuberant 
health.  StiU,  if  a  medical  attendant  see  such  a  patient,  he 
should  warn  the  friends  of  the  risks  they  are  running  in  allowing 
their  relative  to  waste  his  strength  in  restless  excitement. 

If  the  case  is  at  all  acute,  it  is  very  difficult  to  treat  it  out- 
side an  asylum,  unless  ample  means  are  available.  Continual 
restlessness  and  loss  of  control  are  awkward  symptoms  to 
cope  with  in  a  private  house,  and,  when  shouting  and  singing 
are  superadded,  removal  to  an  institution  is  almost  imperative. 
Wherever  the  patient  is,  all  unnecessary  furniture  should  be 
removed  ;  and  a  room  on  the  ground  floor  is  preferable  to  one 
upstairs.     Cases  of  simple  mania  do  not  always  call  for  certifica- 


112  PSYCHOLOGICAL  MEDICINE 

tion,  provided  that  the  patient  can  be  controlled ;  but  where  there 
is  much  arrogance  and  general  exaltation,  effective  manage- 
ment is  almost  impossible  at  home.  Kest  in  bed  is  the  most 
valuable  form  of  treatment  and  best  tends  to  promote  recovery. 
Added  to  this,  partial  isolation,  good  and  liberal  feeding,  and 
attention  to  the  sleep  and  bowels  are  important  points  in  the 
treatment  of  mania.  Massage  is  not  recommended.  Some 
phj^sicians  recommend  plenty  of  exercise  for  their  maniacal 
patients,  believing  that  physical  exhaustion  will  promote 
natural  sleep.  Such  a  practice  is  full  of  danger  and  seems 
to  be  directly  opposed  to  all  experience.  To  exhaust  the  body 
impHes  an  equal  exhaustion  of  the  nervous  elements  ;  the 
greater  the  fatigue,  the  wilder  the  excitement.  Strength  must 
be  conserved  during  the  early  weeks  of  mania,  for  in  this  way 
the  attack  is  shortened.  Further,  it  must  be  borne  in  mind 
that  fatigue  is  not  registered  in  the  maniac  as  it  is  in  the 
sane  person,  and  in  consequence  it  is  very  easy  to  overtax 
his  strength.  Eest  engenders  rest ;  the  more  it  is  indulged 
in,  the  greater  is  the  desire  for  repose.  When  the  excitement 
is  very  intense  it  is  frequently  difficult  to  persuade  a  patient 
to  keep  in  bed,  but  if  left  he  will  usually  sit  covered  up  in 
blankets.  Plenty  of  fresh  air  is  very  important  in  the  treat- 
ment of  these  cases,  and  the  tendency  of  recent  years  has  been 
to  keep  them  in  bed  in  the  open  air,  if  possible  ;  the  beds  in 
some  of  the  acute  mental  hospitals  being  placed  on  verandas. 
The  bowels  must  be  carefully  attended  to,  and  a  dose  of  mineral 
water,  or  some  other  purgative,  may  be  given  with  advantage 
three  or  four  times  a  week. 

Many  excited  patients  are  troublesome  in  taking  food  ;  some 
are  very  capricious,  and  will  take  one  good  meal  and  then  refuse 
the  next,  but  in  the  end  they  will  average  a  fair  amount  of 
nourishment  daily.  Others  refuse  everything  that  is  brought  to 
them,  or  will  only  drink  a  small  cupful  at  a  time.  A  minimum 
standard  must  be  fixed,  and  the  patient  must  be  forcibly  fed  if 
he  does  not  take  this  allowance.  Many  of  these  patients  will 
swallow  only  fluid  food  ;  but  as  this  may  consist  of  several  pints 
of  milk,  four  to  six  eggs,  soup,  etc.,  enough  nourishment  can 
be  taken.  Never  delay  forcible  feeding  if  it  is  considered 
necessary,  as  states  of  excitement  tend  to  produce  exhaustion, 
which  may  terminate  fatally.    All  struggling  with  patients 


MANIA  113 

must  be  avoided  as  far  as  iDossible.  Nothing  must  be  under- 
taken unless  sufficient  help  is  at  hand  to  carry  it  out  without 
injuring  the  patient,  if  he  should  offer  resistance. 

The  insomnia  of  acute  mania  is  most  difficult  to  overcome. 
Patients  will  lie  awake  laughing  and  talking  night  after  night, 
in  spite  of  the  hypnotics  which  are  given.  Chloral,  amylene 
hydrate,  and  sulphonal  are  the  most  useful  sedatives  in  these 
cases.  During  the  day  hyoscin  may  be  given  with  advantage. 
Stimulants  may  be  necessary  in  all  the  more  acute  forms  of 
mania,  but  alcohol  should  be  avoided  if  possible.  The  writer 
finds  that,  if  it  is  possible  by  any  means  to  raise  the  blood- 
pressure  of  these  patients,  a  distinct  lessening  of  excitement  is 
at  once  produced.  Unfortunately,  it  is  not  always  easy  to 
bring  this  about.  The  drugs  which  will  be  found  most  useful 
are  acid,  hydrobrom.  dil.  and  liq.  adrenalin  and  pituitrin  ;  but 
the  period  during  which  the  blood-pressure  is  raised  after 
administration  is  usually  very  short.  As  a  rule,  better  results 
can  be  obtained  by  employing  the  prolonged  bath — the  descrip- 
tion of  which  will  be  found  elsewhere.  Patients  are  placed  in 
this  bath  daily.  The  duration  of  the  first  bath  should  be  half 
an  hour,  with  a  gradual  increase  from  day  to  day,  until  a  duration 
of  six  or  eight  hours  is  attained.  Often  an  excited  patient  will 
be  found  to  be  quiet  and  rational  during  the  bath  and  for  a 
short  time  after.  In  many  ways  the  use  of  the  bath  tends 
to  promote  recovery. 

In  acute  delirious  mania  and  other  forms  of  very  acute 
excitement,  where  there  is  a  tendency  to  collapse,  much  can 
be  done  towards  saving  a  patient's  life  by  the  services  of 
a  good,  conscientious  nurse.  From  the  nursing  standpoint 
these  cases  resemble  those  of  typhoid,  and  consequently  it 
is  a  matter  of  the  utmost  importance  to  have  a  thoroughly 
conscientious  and  experienced  nurse.  Food  must  be  ad- 
ministered, if  necessary,  by  means  of  a  nasal  or  cesophageal 
tube  every  four  hours,  and,  as  a  rule,  six  ounces  of  alcohol 
should  be  given  during  each  twenty-four  hours.  In  these  acute 
cases  it  is  very  necessary  to  watch  carefully  for  local  redness 
or  other  signs  which  may  indicate  the  forming  of  bed-sores. 
The  passing  of  urine  must  be  regularly  recorded.  A  tem- 
perature chart  should  be  kept,  as  a  sudden  accession  of  fever 
may    be    the    first    warning    of    some    intercurrent    disease. 


114  PSYCHOLOGICAL  MEDICINE 

The  administration  of  chloroform  is  of  great  value  in  the 
treatment  of  the  very  acute  forms  of  mania,  the  anaesthetic 
being  given  for  an  hour  a  day  for  two  or  three  days. 

When  convalescence  has  set  in,  plenty  of  time  must  be 
given  for  the  patient  to  recover  his  physical  health.  The 
nervous  system  will  require  many  weeks  of  rest,  and  it  is  very 
unwise  to  remove  the  case  from  the  institution  or  house  in 
which  it  has  been  treated  until  sleep  has  fully  returned  and 
all  the  physical  functions  are  re-established.  The  period 
of  convalescence  is  frequently  very  trying,  both  to  the 
patients  and  his  friends,  and  unfortunately  it  is  by  no  means 
common  for  the  latter  to  decide  upon  some  rash  step,  which 
ultimately  ends  in  disaster.  This  question  is  so  fully  dealt  with 
in  the  chapter  on  Treatment  that  it  is  unnecessary  further 
to  discuss  it  here. 

In  conclusion,  it  should  be  pointed  out  that  if  there  is  any 
special  cause  for  the  excitement,  this  must  be  treated  in  addi- 
tion to  attending  to  the  various  symptoms  as  they  arise. 
The  treatment  must  be  directed  towards  improving  the  bodily 
condition,  as  well  as  quietening  the  mind,  and  in  many  ways 
the  former  may  be  said  to  be  the  more  important  of  the  two. 
When  the  patient  has  recovered,  tell  him  how  he  must  live 
in  the  future  so  that  he  may  avoid  any  recurrence  of  his 
illness.  If  he  should  have  a  second  attack,  he  and  his 
friends  should  recognise  the  symptoms  earlier  than  on  the 
first  occasion  and  thus  reduce  the  risk  of  a  serious  break- 
down by  taking  immediate  action.  If  the  patient  is  suffering 
from  the  mixed  form  of  maniacal- depressive  insanity,  his  rela- 
tives must  be  warned  to  watch  for  symptoms  of  depression. 
In  no  case  should  a  patient  be  allowed  to  go  back  to  work 
for  some  months  after  his  illness,  and  it  should  always  be 
remembered  that  it  is  the  method  of  treatment  during  the 
next  few  years  which  will  go  far  towards  confirming  the 
nervous  system  and  re-establishing  health. 


115 


CHAPTEE  VII 

MELANCHOLIA  AND  STATES   OF  DEPRESSION 

Formerly  all  states  of  depression  were  included  under  the 
generic  term  Melancholia  ;  any  attempts  at  differentiating 
various  types  were  chiefly  confined  to  whether  the  patient 
was  resistive  or  agitated,  or,  in  other  words,  whether  there 
was  motor  restlessness  associated  with  the  mental  depression. 
During  recent  years  there  has  been  a  growing  tendency  to 
differentiate  states  of  depression  according  to  the  grouping  of 
the  symptoms  and  the  general  type  of  the  case.  As  with  other 
forms  of  mental  disease,  a  disorder  which  was  at  one  time 
considered  an  undivided  whole  is  now  found  to  be  an  aggre- 
gation of  disorders,  for  the  mistake  was  made  of  naming  the 
disease  according  to  its  most  prominent  symptom.  Depression 
is  common  to  many  types  of  insanity,  but  to  call  all  these 
types  Melancholia  is  a  misnomer  and  tends  to  confusion. 

At  the  present  day  the  study  of  mental  disease  is  still  in 
its  infancy,  and  change  in  nomenclature  is  to  be  expected  as 
from  time  to  time  it  is  found  that  diseases  formerly  regarded 
as  distinctive  are  in  reality  compound.  Many  forms  of  insanity 
are  still  necessarily  named  after  their  most  prominent  mental 
symptom.  The  student  should  clearly  understand  that  such 
terms  as  Mania  and  Melancholia  merely  designate  growps  of 
symptoms.  From  a  diagnostic  point  of  view  this  state  of 
things  is  unsatisfactory ;  groups  of  symptoms  are  apt  to 
change,  and  not  infrequently  the  name  of  the  disease,  which 
is  really  descriptive  of  the  condition  of  the  moment,  has  to  be 
altered  with  the  variation  in  the  condition.  Thus  the  melan- 
choliac  of  to-day  may  be  the  maniac  of  to-morrow  and  the 
dement  of  six  months  hence.  All  this  is  very  confusing  to 
the  student  ;  but  though  the  advance  is  slow,  progress  is  taking 


116  PSYCHOLOGICAL  MEDICINE 

place,  and  more  accurate  diagnosis  can  be  made  to-day  than 
was  possible  some  years  ago.  Differences  are  more  clearly 
distinguished,  and  differentiation  between  types  of  mental 
disease  is  more  minute  than  in  the  past.  Kraepelin  has  done 
a  very  great  deal  to  further  more  accurate  diagnosis  and 
prognosis,  correctness  in  the  latter  depending  largely  on 
accuracy  in  the  former. 

States  of  depression  are  found  associated  with  many  forms 
of  insanity.  A  layman  can  diagnose  that  a  man  is  melan- 
chpHc,  but  the  physician  should  try  to  find  out  why  his 
patient  is  depressed.  Depression  may  be  the  whole  or  para- 
mount condition,  or  it  may  merely  be  a  symptom  in  a  grave 
disease  such  as  general  paralysis.  It  may  be  a  symptom 
merely  indicative  of  a  mental  state,  or  it  may  be  associated 
with  other  symptoms  which,  when  taken  together,  connote 
progressive  mental  deterioration.  Melanchoha  has  been 
defined  by  Mercier  as  a  '  disorder  characterised  by  a  feeling 
of  misery,  which  is  in  excess  of  what  is  justified  by  the  circum- 
stances in  which  the  individual  is  placed.'  This  definition, 
it  should  be  remembered,  deals  only  with  the  mental  state 
and  in  no  Avay  explains  the  origin  of  the  depression. 

etiology. — Some  forms  of  melancholia  occur  only  in  the 
j'"ears  of  decadence  and  not  before  middle  life,  but  the  varieties 
of  depression  formerly  known  as  Eecurrent  Melanchoha  and 
Folie  Circulaire  usually  show  themselves  earlier.  Depression 
is  rather  more  common  among  women  than  men.  An  unstable 
inheritance  is  found  in  a  fairly  large  proportion  of  cases, 
especially  in  those  in  which  the  break-down  occurs  early  in 
life.  Phthisis  is  often  found  in  the  family  history,  and,  if 
combined  with  any  neuroses,  it  increases  the  liability  to 
insanity  in  the  offspring.  Monotonous  and  anxious  occu- 
paHons  are  factors  which  may  predispose  to  depression. 
Certain  types  of  mental  constitution  are  more  liable  than 
Others  to  lead  to  melancholia.  Long-continued  periods  of 
insomnia  are  frequently  followed  by  a  depression  of  a  more 
or  less  severe  kind.  Many  melancholiacs  will  tell  you  that 
they  seldom  drink  water  and  will  also  give  a  long  history  of 
Severe  constipation.  Certain  periods  of  life,  when  stresses  are 
Apt  to  weigh  heavily  on  the  organism,  must  also  be  classed 
among  the  commoner  cases  of  depression.     In  the  female  we 


MELANCHOLIA  AND  STATES  OF  DEPRESSION  117 

find  the  following:  pregnancy,  lactation,  climacteric,  and 
senility.  Lastly,  there  are  the  so-called  mental  shocks — -such 
,as  loss  of  relatives  and  financial  failure. 

Varieties,- — There  are  several  recognised  forms  of  mentiil 
disorder  in  which,  depression  is  the  most  marked  symptom. 
Attacks  of  melancholia  may  occur  periodically  throughout 
the  life  of  soma  persons,  in  the  same  way  that;  others  may  suffer 
from  cyclic  attacks  of  excitement.  Many  writers  prefer  to 
use .  the  old  term  '  periodic  '  ^  or  '  recurrent  '  melancholia  for 
these  cases,  or,^  if  the  mental  disorder  is  an  alternation  betWeeii 
depression  and  mania,  the  terni  Circular  Insanity  or  Folie 
Circulaire  is  employed.  Kraepelin  has  introduced  the  nam^ 
Maniacal-Pepressive  Insanity  for  these  cases.  He  considers  that 
-disorders  of  this  kind  are  not  accidental  in  character,  but  that 
they,  are  a  definite  grouping  of  symptoms  which  _  are  quite 
distinguishable  from  other  forms  of  depression— and  in  this 
the  writer  entirely  agrees.  Kraepelin  is  undoubtedly  a  keen 
observer,  and  he  shows  that  these  recurrent  disorders  follow 
.a!  definite  course,  which  is. usually  repeated  in  each  succeeding 
attack.  He  describes  three  varieties  of  maniacal-depressive 
insanity  :  the  Maniacal,  the  Depressive,  and  the  Mixed.  Older 
writers  would  describe  these  as  Eecurrent  Mania,  Eecurrent 
Melancholia,  and  Folie  Circulaire.  Melancholia,  for  the  present 
purpose,  may  be  classed  under  the  following  heads  : — 

1.  Simple  Melancholia. — A  condition  in  which  there  arp 
usually  no  delusions,  and  in  which  the  physical  health  is  not 
seriously  affected.  This  disorder  usually  first  appears  early 
in  life,  and  has  a  tendency  to  recur  periodically,  or  may 
alternate  with  a. cycle  of  excitement.  Patients  suffering  froim 
the  simple  form  may  have  repeated  attacks,  alivays  of  this 
mild  type,  but' they  never  become  weak-minded,  or  the  attacks 
may  tend  to  become  more  severe. 

In  the  more  serious  variety  the  melancholia  and  the  alternat- 
ing mania,  when  it  occurs,  are  of  a  severe  nature,  and  there 
is  a  greater  tendency  for  the  patient  to  pass  into  dementia. 

2.  Melancholia  and  Hypochondriacal  Melancholia. — This 
.disorder  more  commonly  occurs  after  middle  life. 

..  S.  Eecurrent  Melancholia  (Maniacal- Depressive). — -This 
may  be  either  simple  or  acute  Mania  in.  the  character  of 
^.symptoms. 


118  PSYCHOLOGICAL  MEDICINE 

4.  Chronic  Melancholia. — This  condition  usually  appears 
after  middle  life.  The  symptoms  are  very  similar  to  those 
found  in  acute  melancholia,  though  of  a  more  sub-acute  type, 
and  there  is  often  a  tendency  to  motor  restlessness. 

Some  authorities  describe  other  varieties  of  melancholia — 
such  as  agitated  melancholia,  where  there  is  an  excess  of  move- 
ment, and  resistive  melancholia  where  there  is  resistance  to 
nursing,  etc.  ;  stuporous  melancholia  where  there  is  defective 
voluntary  movement.  Depression  also  occurs  in  other  con- 
ditions, and,  in  fact,  may  be  a  symptom  in  many  diseases. 
It  is  therefore  all  the  more  incumbent  on  the  physician  to  be 
careful  in  his  diagnosis.  The  mental  state  of  a  fair  propor- 
tion of  general  paralytics  is  one  of  depression,  but  dementia 
paralytica  must  not  be  diagnosed  from  the  mental  symptoms 
alone  ;  this  disease  is  physical,  the  mental  disorder  being 
secondary.  A  prudent  physician  will  always  seek  for  physical 
signs  of  organic  disease  before  committing  himself  to  a  diagnosis. 

Prodromata. — Melancholia  usually  develops  slowly,  though 
in  its  recurrent  forms  subsequent  attacks  may  be  sudden  in 
onset.  As  a  general  rule  the  patient  gradually  becomes  more 
and  more  depressed.  He  may  have  weeks  of  sleeplessness, 
and  there  is  a  slow  but  steady  loss  of  the  body  weight.  He 
loses  interest  in  his  work  and  surroundings,  attention  fails, 
and  everything  becomes  a  burden.  It  is  often  very  difficult 
to  say  when  the  line  of  demarcation  between  sanity  and 
insanity  has  been  crossed,  as  the  reasoning  power  is  not  lost 
so  early  as  it  is  in  mania. 

Mental  Symptoms. — (1)  Simple  Melancholia. — In  this  con- 
dition there  is  merely  a  general  feeling  of  depression  and 
slowing  of  mental  action.  Savage  defines  the  state  as  being 
a  *  saturated  solution  of  grief.'  These  patients  are  self- 
absorbed,  and  there  is  a  rise  of  subject-consciousness  and  fall 
of  object-consciousness.  They  feel  a  sense  of  resistance  to 
their  environment,  and  lose  interest  in  all  their  former  pursuits. 
Thought  is  difficult,  and  there  is  a  general  sense  of  inability 
to  do  their  daily  work  ;  thus  they  become  unoccupied.  Speech 
is  slow  and  betrays  effort.  They  become  untidy  and  careless  in 
dress  and  personal  cleanliness,  and  food  is  distasteful  to  them. 

These  patients  must  always  be  treated  as  potential  suicides  ; 
but  with  simple  melancholia  it  is  not  common  to  find  serious 


MELANCHOLIA  AND  STATES  OP  DEPRESSION  119 

attempts  at  self-destruction.  Depression  is  more  acute  in 
the  early  hours  of  the  morning,  and  often  by  evening  the 
patient  is  able  to  take  interest  in  the  affairs  of  others. 
Hallucinations  and  delusions  are  not  present  ;  a  patient 
may  have  a  vague  fear  that  he  will  be  unable  to  work  again. 
After  some  weeks  or  months  these  cases  usually  recover, 
but  the  tendency  is  for  them  to  have  recurrent  attacks  of  a 
similar  kind. 

2.  Melancholia  and  Hypochondriacal  Melancholia. — In  this 
disorder  all  the  symptoms  mentioned  under  the  head  of  Simple 
Melancholia  are  present  but  more  marked.  There  is  greater 
evidence  of  dissolution,  both  physically  and  mentally.  The 
onset  is  usually  slow  and  steady,  with  short  periods  of  remis- 
sion, during  which  the  patient  appears  brighter  and  more 
cheerful.  It  is  largely  owing  to  this  gradual  onset  that  so 
many  patients  are  left  untreated,  and  the  condition  is  not  un- 
commonly chronic  before  the  physician  is  called  in.  When  the 
disorder  is  fully  developed  there  is  severe  mental  depression  ; 
there  is  a  very  great  rise  of  subject  consciousness,  and  the 
patient  is  more  and  more  introspective.  Attention  fails  for 
external  things,  and  is  centred  on  subjective  thoughts  and 
feelings  of  a  dismal  kind.  With  all  this,  there  is  a  profound 
loss  of  interest  in  environment  and  inability  to  do  the  daily 
work.  The  melancholic  mother  neglects  her  house  and 
children,  and  to  her  everything  seems  to  be  confusion.  Self- 
accusation  very  soon  appears  as  a  prominent  symptom,  for 
the  tendency  of  human  nature  is  to  explain  new  feelings 
and  thoughts.  It  is  this  tendency  to  explain  and  desire  to 
account  for  everything  that  leads  to  the  production  of  so  many 
delusions. 

Symptoms  and  circumstances  are  all  viewed  from  the 
gloomy  side,  and  the  patient  turns  to  the  '  unknown  '  for  his 
explanations.  To  the  conscientious  person  there  is  no  subject 
so  fraught  with  possibilities  for  this  purpose  as  reUgion,  as 
there  the  melancholiac  can  find  the  condemnation  which  he 
seeks.  As  has  been  already  stated  in  the  chapter  on  Causation 
of  Insanity,  religion  is  far  more  closely  connected  with  the 
explanation  of  unaccustomed  symptoms  than  an  actual  factor 
in  the  production  of  melancholia.  The  layman  would  have 
us  believe  that  rehgious  excitement  is  the  cause  of  the  mental 


120  PSYCHOLOGICAL  MEDICINE 

disorder  ;  in  a  vast  proportion  of  cases  this  is  not  so,  the 
religious  element  being  purely  secondary  to  the  insanity. 
It  seems  at  times  almost  incredible  that  the  patient  really 
beheves  all  he  says,  so  trivial  are  the  matters  upon  which 
his  self -accusation  is  based  ;  but  these  delusions,  it  must  be 
remembered,  are  not  founded  on  past  experience,  but  upon 
behef.  Some  persons  seem  capable  of  making  themselves 
believe  anything ;  and,  once  the  belief  is  present,  plenty 
of  evidence  in  support  of  it  is  readily  forthcoming,  no  matter 
how  absurd  the  original  idea  may  be.  For  the  same  reason 
argument  is  of  no  avail,  since  the  belief  is  a  faith,  and  not  based 
on  fact  or  experience.  A  patient  may  even  go  back  to  his 
early  hfe  in  his  endeavour  to  find  a  cause,  and  may  ultimately 
accuse  himself  of  having  stolen  two  stamps  when  he  was  young 
or  in  his  first  position  of  trust.  He  distorts  earty  indiscretions 
into  gigantic  sins,  and  even  the  ordinary  incidents  of  life  may 
be  misconstrued  into  vice.  Some  patients  say  and  believe  that 
they  are  '  lost '  for  ever,  and  that  they  have  committed  some 
'  unpardonable  sin  '  ;  and,  when  pressed  to  state  what  the  sin 
is,  cannot  do  so.  They  feel  that  they  have  sinned,  and  that  is 
sufficient,  just  as  another  feels  that  he  is  ruined,  notwithstand- 
ing that  he  has  a  large  balance  at  the  bank.  Fear  of  being  sent 
to  prison  is  another  common  delusion.  Extreme  apprehension 
of  some  impending  harm  fills  many  melanchohacs  with  alarm  ; 
they  misinterpret  every  sound  and  action  into  the  movements 
and  preparations  of  their  persecutors.  '  The  world  is  changed, 
and  everyone  in  it,'  is  the  cry  of  some,  faiHng  to  realise  that 
the  change  is  in  themselves. 

Hallucinations  do  not  usually  occur  in  acute  melancholia  ; 
if  present,  they  usually  indicate  that  there  is  a  tendency  to 
exhaustion,  or  that  the  case  is  not  purely  one  of  depression.  A 
certain  proportion  of  patients  develop  exhaustion  symptoms 
during  an  illness  of  this  type,  and  it  is  when  this  takes  place 
that  sensory  disturbances  appear ;  when  present,  they 
usually  tend  to  confirm  the  patient  in  his  beliefs,  etc.  The 
unpardonable  sinner  hears  the  '  voice  of  God  '  proclaiming 
that  he  is  '  lost,'  and  constantly  sees  '  devils  '  around  him  ; 
he  may  even  go  so  far  as  to  smell  brimstone.  The  hallucina- 
tions which  are  associated  with  melancholia  frequently  reflect 
the  type  of  the  patient's  education  and  training.     He  believes 


me;<ancholia  and  states  of  depression         121 

that  he  is  '  lost,'  and  at  once  the  hell  of  his  personal  creed 
appears  about  him. 

The  melancholiac  is,  as  a  rule,  able  to  converse,  and  will 
answer  questions  ;  but  his  thoughts  keep  reverting  to  the 
same  depressing  and  gloomy  ideas,  though  with  an  effort  he 
can  direct  his  attention  to  other  things.  Thought  is  very 
slow,  and  a  patient  will  frequently  repeat  a  question  put  to 
him  in  order  to  gain  time.  Memory  is  slow  and  lacking  in 
receptive  power,  but  is  otherwise  good.  The  conduct  is  in 
keeping  with  the  mental  condition.  Many  of  these  patients 
will  sit  unoccupied  for  hours,  and  even  days  and  weeks.; 
others  will  stand  still,  looking  the  picture  of  abject  misery. 
They  lose  all  interest  in  dress  and  personal  appearance  and 
.are  slovenly  in  their  habits.  They  neither  wash  nor  clothe 
themselves  unless  made  to  do  so  by  others. 

Many  of  the  insane,  and  especially  melancholiacs,  are  abso- 
lutely consistent  ;  if  they  consider  that  it  is  wrong  to  eat, 
or  wicked  to  do  any  particular  thing,  they  will  deny  them- 
selves, no  matter  how  painful  the  denial  may  be.  The  sane 
are  constantly  adapting  themselves  to  altered  circumstances 
and  in  this  way  may  be  inconsistent  ;  but  it  is  not  so  with 
the  insane.  Suicidal  attempts  of  all  kinds  are  frequent  among 
melancholiacs  ;  some  will  spend  their  days  scheming  how  to 
destroy  themselves.  In  rare  instances  a  melancholiac  will 
kill  his  own  family  and  then  commit  suicide. 

Hypochondriacal  melancholia  is  a  type  of  ordinary  melan- 
cholia, which  chiefly  differs  from  the  above  in  that  a  patient, 
instead  of  explaining  his  symptoms  from  the  mental  stand- 
point, refers  all  his  troubles  to  some  physical  disease.  These 
hypochondriacal  ideas  may  develop  at  any  period  of  life,  but 
are  more  common  in  the  middle  and  later  epochs.  In  some 
cases  hypochondriacal  melancholia  seems  to  grow  out  of  a 
natural  tendency,  though  there  are  many  hypochondriacal 
persons  who,  in  spite  of  lifelong  worry  about  their  health, 
never  lapse  into  insanity.  There  is  a  difference  between  the 
ordinary  melancholiac  and  his  hypochondriacal  brother,  for 
the  former  sees  no  hope  before  him  and  believes  that  neither 
God  nor  man  can  help  him,  while  the  latter  is  always  hoping 
and  expecting  to  discover  some  one  or  something  that  can  cure 
him.     The  hypochondriac  describes  his  troubles  to  everyone;; 


122  PSYCHOLOGICAL  MEDICINE 

the  melancholiac  broods  over  thera.  Some  authorities  believe 
that  the  hypochondriac  is,  to  a  great  extent,  conscious  of  the 
workings  of  his  abdominal  organs.  It  is  probably  true  that 
certain  organic  sensations  are  deeply  affected,  for  we  know 
what  an  influence  abnormal  sensations  or  the  absence  of 
normal  sensations  have  on  the  idea  of  self. 

There  are  several  varieties  of  hypochondriacal  melanchoHa  : 

(a)  Brain  Hypochondriasis. — These  patients  frequently  believe 
that  their  thoughts  take  shape  and  can  therefore  be  read. 
Such  persons  usually  seek  seclusion.  Others  believe  that  their 
brains  are  diseased  and  do  not  work  properly.  This  form  of 
melancholia  is  most  common  in  middle  and  later  life. 

(&)  Sexual  Hypochondriasis.— This  is  more  frequently 
found  in  early  adult  life  and  in  very  neurotic  subjects  with 
an  unstable  inheritance.  Sexual  excesses  are  at  times  the 
exciting  cause,  or  the  reading  of  quack  literature  may  be  the 
original  disturbing  element.  Ideas  of  impotency  have  led  to 
suicide  on  the  eve  of  marriage,  and  it  is  wise  to  treat  all  sexual 
hypochondriacs  as  suicidal. 

(c)  Gastro- Intestinal  Hypochondriasis. — This  includes  those 
persons  with  ideas  of  throat  or  bowel  obstruction.  The  former 
are  frequently  quite  young  patients,  who  believe  that  their 
throat  is  closed  up  and  that  they  cannot  swallow,  or  that 
they  suffer  from  cancer  of  the  throat.  This  condition  is  also 
found  after  middle  life.  Eefusal  of  food  is  usually  the  most 
difficult  symptom  to  treat  and  may  necessitate  the  early 
removal  of  such  a  patient  to  an  asylum.  Ideas  of  bowel 
obstruction  are  fairly  common,  and  have  been  referred  to  as 
the  symptom  of  true  hypochondriasis.  Many  of  these  patients 
believe  that  their  abdomen  is  a  huge  sack,  and  that  food  is 
accumulating  there  in  large  quantities.  They  may  tell  you 
that  their  bowels  have  not  been  opened  for  years,  and  that 
they  feel  that  they  are  becoming  more  and  more  distended 
every  day.  They  are  usually  very  suicidal  and  troublesome 
in  the  matter  of  food,  having  to  be  fed  by  means  of  a 
stomach  tube.  Altered  intestinal  and  abdominal  sensations 
probably  account  for  certain  of  the  symptoms,  and  it  is  of 
interest  to  note  that  the  lumen  of  the  intestinal  tract  has 
been  found  to  be  much  narrower  in  patients  dying  from  this 
condition.     There  is  one  other  class  of  intestinal  hypochon- 


MELANCHOLIA  AND  STATES  OF  DEPRESSION  123 

driasis  which  has  been  referred  to  by  Savage,  and  which  is 
one  of  medico-legal  interest.  Certain  patients  have  the  belief 
that  they  have  no  control  over  the  lower  bowel  and  may 
prepare  to  relieve  themselves  in  pubHc  places  without  any 
thought  of  indecent  exposure. 

(d)  General  Hypochondriasis. — These  patients  believe  that 
they  have  some  general  disease — such  as  hydrophobia  or 
syphilis.  They  may  show  their  mental  aberration  by  con- 
stantly washing  themselves  or  the  vessels  they  use  for  food. 
They  refuse  to  shake  hands  and  withdraw  themselves  from 
others  lest  they  should  infect  them.  Disordered  conduct 
often  reflects  many  of  the  ideas  and  thoughts  of  these  patients. 
In  all  forms  of  hypochondriacal  melancholia,  in  addition  to  those 
named,  the  ordinary  symptoms  of  melancholia  are  generally 
present.  Disorders  of  the  emotions  and  attention,  disorders 
of  conduct,  and  disorders  of  nutrition  all  occur.  These 
symptoms  need  not  be  repeated  here  in  detail,  as  they  will 
be  found  under  the  heading  of  Physical  Symptoms  in  Melan- 
cholia. The  physician  must  remember  that,  though  hypochon- 
driasis is  usually  found  in  patients  in  whom  no  known  bodily 
disease  can  be  diagnosed,  it  may  be  associated  with  organic 
disease,  the  hypochondriacal  symptoms  being  in  reality  the 
patient's  misinterpretation  of  true  physical  signs.  Thus, 
in  locomotor  ataxy  a  person  may  misconstrue  the  gastric  and 
rectal  crises  into  the  belief  that  his  stomach  and  intestines 
are  being  tampered  with,  or  that  some  one  is  twisting  them  by 
means  of  electricity. 

3.  Becurrent  Melancholia  (Maniacal-Depressive). — Eecurrent 
melancholia  is  a  disorder  which  usually  appears  in  early  adoles- 
cence and  formerly  was  looked  upon  as  ordinary  melancholia. 
In  many  points  it  resembles  ordinary  melancholia,  but  it 
differs  in  that  it  develops  earlier  in  life  and  tends  to  recur 
or  to  alternate  with  periods  of  excitement.  The  emotional 
disturbances  may  be  very  profound,  and,  as  a  result,  delusions 
of  all  kinds  may  develop.  The  false  beliefs  may  be  those  of 
being  '  lost,'  '  forsaken  for  ever  '  ;  they  may  take  the  form 
of  self- accusations,  or  they  may  relate  to  the  bodily  organs 
and  functions  and  be  hypochondriacal  in  character.  If  the 
exhaustion  symptoms  have  supervened,  these  delusions  may 
be  corroborated  and  supported  by  hallucinations  and  illusions, 


124  PSYCHOLOGICAL  MEDICINE 

and  in  every  way  the  conduct  and  physical  symptoms  re- 
semble those  observable  in  ordinary  melancholia.  These 
patients  may  attempt  suicide  in  the  early  weeks  of 
depression. 

Usually  within  eight  or  ten  months  the  mental  and  bodily 
symptoms  disappear,  and  the  depression  is  followed  by  a 
period  of  apparent  health.  This  may  last  for  some  months  or 
even  years,  when  there  is  a  return  of  all  the  old  symptoms, 
and  they  pass  through  another  attack  which  may  resemble  the 
former  in  almost  every  particular.  On  the  other  hand,  there 
may  be  only  a  few  weeks  of  apparent  health,  and  then  it  is 
noticed  that  the  patient  seems  to  be  almost  too  bright  with 
an  exaggerated  sense  of  well-being.  As  time  passes,  definite 
excitement  sets  in,  with  a  stage  of  acute  mania,  which  in 
tm-n  is  followed  by  a  stuporose  condition,  and  then  health. 
Sooner  ox  later  mental  disorder  again  appears,  and  the  cycle 
is  gone  through  once^  more.  The  periods  of  health  become 
less  marked,  both  in  length  of  time  and  in  completeness,  and 
the  excitement  and  depression  follow  each  other  more  closely. 

4.  Chronic  Melancholia.- — As  already  stated,  the  symptoms  in 
this  condition  are  very  similar  to  those  found  in  the  more  acute 
variety  of  depression,  except  that  they  are  more  sub-acute  in 
character  and  often  complicated  by  conditions  of  motor 
agitation  and  general  restlessness  and  resistance.  It  is  the  type 
of  depression  which  occurs  more  commonly  after  middle  life, 
and  the  symptoms  may  persist  with  little  change  for  many  years.. 

Physical  Symptoms. — Gastro- Intestinal  System. — The  tongue 
is  furred,  appetite  bad,  and  there  may  be  absolute  refusal 
of  food.  Constipation  is  an  almost  constant  symptom,  and 
at  times  it  is  very  severe  and  requires  active  treatment.  The 
toxicity  of  the  gastric  juice  is  greater  than  normal,  and  there 
is  said  to  be  an  increase  of  hydrochloric  acid  and  deficiency 
of  pepsine  in  it. 

Circulatory  System. — The  pulse  is  slow  and  of  high  tension^ 
the  blood -pressure  being  very  high  in  some  cases  ;  but  where 
the  depression  is  the  result  of  exhaustion  or  when  associated 
with  extreme  exhaustion,  the  blood-pressure  is  low.  There 
may  be  cedema  of  the  feet  and  legs  due  to  blood  changes, 
and  some  patients  are  anaemic. 

Bes'piratory  System. — The  breathing  is  slow,  and  the  move- 


MELANCHOLIA  AND  STATES  OF  DEPRESSION  ^  125 

ments   of  the   chest    are   shallow,    and    on   auscultation   the 
respiratory  sounds  can  only  be  heard  with  difficulty. 

Genito-Urinary  System. — The  urine  is  diminished  in  quan- 
tity, and  the  amount  of  urea  excreted  is  considerably  less  than 
normal.  The  catamenial  periods  in  the  female  are  either 
absent  or  lessened  in  amount  and  frequency. 

Nervous  System. — Neuralgia  is  not  uncommon  in  the  in- 
cipient stages  of  melancholia.  In  true  melanchoha,  patients 
frequently  complain  of  a  feeling  of  weight  on  the  top  of  the 
head,  or  a  sensation  hke  a  tight  band  round  the  cranium. 

Skin  and  Appendages. — The  skin  and  appendages  suffer 
from  nutritional  changes.  Small  pustules  may  develop  ;  the 
hails  are  friable,  furrowed,  and  contain  opaque  patches ; 
the  hair  is  dry  and  brittle  and  loses  its  lustre  ;  and  there  may 
be  areas  of  pigmentation  in  the  skin.  Stoddart  found  the  per- 
spii'ation  very  defective  in  melancholic  conditions,  and,  even 
when  treated  with  drugs — such  as  pilocarpine  and  jaborandi — 
the  reaction,  if  any,  was  very  slight.  This  is  very  striking  when 
compared  with  mania. 

The  Muscular  System  has  been  carefully  investigated  by 
Stoddart,  who  states  that  melancholiacs  suffer  from  paralysis 
and  rigidity  of  the  muscles  of  the  spinal  column  and  of  the 
large  proximal  joints  ;  while  the  movements  of  the  wrists, 
fingers,  ankles,  and  toes  are  comparatively  unimpaired.  These 
symptoms  are  very  slight  in  mild  cases,  but  decidedly  m^arked 
in  the  more  severe  forms  of  melancholia.  Thus  the  move- 
ments in  the  melancholiac  are  largely  peripheral  movements 
of  the  fingers  and  smaller  joints,  while  in  larger  joints  rigidity 
may  be  detected.  The  movements  are  slow,  and  the  patient 
states  that  he  has  difficulty  in  doing  things.  He  walks  slowly 
and  the  movements  appear  to  be  more  from  the  knees  than  from 
the  hips.  It  may  be  impossible  for  the  patient  to  write  and, 
if  he  does,  it  is  with  great  effort. 

Some  melancholiacs  complain  that  objects  look  blurred  to 
them  ;  on  examination  it  will  be  found  that  it  is  only  near 
objects  that  seem  to  be  out  of  focus,  showing  that  the  blurring 
of  objects  is  due  to  weakness  of  accommodation.  This  may, 
to  a  certain  extent,  explain  the  frequency  with  which  these 
patients  mistake  identity.  The  body  weight  usually  falls 
rapidly,    and    at   times   there   may   be   marked    emaciation. 


126  PSYCHOLOGICAL  MEDICINE 

Sleep  is  bad  in  all  forms  of  depression,  but  the  insomnia  is 
more  marked  in  severe  cases.  There  may  be  difficulty  in 
getting  off  to  sleep,  or  the  patient  may  wake  early,  and 
even  the  sleep  that  is  obtained  is  disturbed  by  disagreeable 
dreams.  Eeaction  times  are  all  slowed.  The  superficial 
reflexes  are  diminished,  but  the  deep  tendon  reflexes  may  be 
increased. 

Course. — Melancholia  may  run  a  long  course  :  some  patients 
apparently  recover  after  many  years.  Depression  occurring 
in  early  life  usually  disappears  after  six  or  eight  months, 
but  only  to  recur  in  a  few  months  or  years.  The  physical 
health  generally  improves  first,  being  quickly  followed  by  the 
mental.  Depression  which  has  formerly  lasted  all  day  passes 
off  in  the  afternoon  or  evening,  and  becomes  less  in  intensity, 
as  well  as  in  duration,  as  the  weeks  and  months  pass.  Sleep 
improves,  and  dreams  which  were  originally  terrifying  and 
disagreeable  become  more  pleasant.  When  this  takes  place 
the  prognosis  is  nearly  always  good.  The  delusions  have 
less  influence  on  the  patient,  and  though  he  may  still  believe 
that  they  were  true,  he  now  regards  them  as  a  horrible  dream 
that  has  passed.  As  improvement  goes  on  the  patient  takes 
more  interest  in  his  personal  appearance  and  his  surroundings, 
and  females  will  inquire  after  their  trinkets  and  dress.  As  in 
health  so  in  disease,  some  days  are  less  pleasant  and  cheerful 
than  others,  and  this  is  very  marked  in  melancholia.  Ee- 
covery  may  be  sudden  and  rapid,  especially  in  the  recurrent 
types  of  this  disorder.  Such  an  event  is  by  no  means  hope- 
ful, as  a  sudden  relapse  may  as  quickly  follow.  If  a  patient 
is  not  recovering,  emaciation  may  be  a  prominent  symptom, 
and  general  nutritional  failm'e  may  terminate  in  death  or 
predispose  to  some  intercurrent  disease,  such  as  phthisis.  In 
those  cases  which  are  chronic,  the  delusions  become  more 
systematised,  and  hallucinations  may  appear  together  with 
signs  of  general  intellectual  deterioration,  or  they  may  pass 
into  a  general  condition  of  apathy. 

Diagnosis. — Depression  itself  is  comparatively  easy  to 
diagnose  :  the  difficulty  arises  when  it  has  to  be  determined 
whether  the  patient  is  certifiably  insane.  The  physician  must 
endeavour  to  discover  the  cause  of  the  depression,  and  whether 
it  is  dependent  on  some  organic  disease.     Never  fail  to  look 


MELANCHOLIA  AND  STATES   OF  DEPRESSION  127 

for  symptoms  of  general  paralysis.  If  the  memory  is  found 
to  be  seriously  affected,  in  all  probability  the  condition  is  due 
to  some  progressive  disease.  Weak-mindedness  may  at  times 
be  confused  with  melancholia,  but  with  the  former  the  body 
weight  is  usually  satisfactory  and^  food  is  taken  ravenously. 
Moreover,  the  conduct  differs  in  the  two  conditions.  The 
melancholiac  is  unoccupied  because  he  is  preoccupied  with 
his  own  thoughts,  but  the  dement  is  idle  from  general  apathy 
and  indolence.  The  recurrent  forms  of  melancholia  can  be 
distinguished  from  the  ordinary  type  of  melancholia,  as  they 
appear  earlier  in  life  and  are  of  more  rapid  onset.  It  may 
be  at  times  difficult  to  distinguish  between  the  recurrent  forms 
of  melancholia  and  dementia  praecox  ;  but  as  the  physical 
and  mental  characteristics  of  the  two  conditions  are  quite 
different,  this  difficulty  should  be  soon  overcome.  Hypo- 
chondriasis may  be  difficult  to  distinguish  from  hypochondriacal 
melancholia  ;  but  in  the  former  the  patient  is  more  able  to 
direct  his  attention  to  his  work  or  occupation,  he  is  more 
hopeful  of  his  recovery,  and  he  will  never  tire  of  trying  new 
remedies. 

Prognosis. — The  immediate  prognosis  is  fairly  good  in  those 
cases  which  break  down  early  in  life,  though  the  ultimate 
prognosis  is  not  good,  as  these  cases  usually  recur.  With  care 
a  great  deal  can  be  done  to  prevent  a  relapse  ;  patients  of  this 
type  should  be  taught  how  to  live  and  the  prophylactic 
measures  that  they  should  follow.  With  each  relapse  the 
prognosis  becomes  less  favourable. 

In  the  ordinary  melancholia  of  middle  life  the  prognosis  is 
fair ;  about  twenty-five  per  cent,  recover  and  keep  well, 
and  a  further  twenty  per  cent,  improve  enough  to  be  able  to 
be  sent  home  and  may  in  time  be  able  to  do  some  work. 
Another  fifteen  per  cent,  improve,  to  a  certain  extent,  both 
physically  and  mentally  :  former  delusions  become  less 
marked,  but  they  remain  apathetic  and  are  unfit  to  work, 
as  prolonged  intellectual  effort  brings  about  a  return  of  the 
depression.  Frequently  these  persons  keep  fairly  well  in  an 
institution  where  the  regular  life  suits  them,  and  they  may 
even  be  able  to  spend  several  days  away  with  their  friends  ; 
but,  if  they  leave  altogether,  they  relapse  within  a  short  time. 
About  35  per  cent,  remain  permanently  depressed,  but  some 


128  PSYCHOLOGICAL  MEDICINE 

patients  may  recover  after  many  years.  Five  per  cent,  die 
during  the  acute  phase  of  the  illness. 

Persistent  hallucinations  of  hearing  are  unfavourable  ;  and 
in  the  same  way  marked  deterioration  and  degradation,  evi- 
denced by  such  acts  as  the  eating  of  filth  and  inattention  to 
the  calls  of  nature,  are  of  gloomy  portent.  If  there  is  great 
dissolution,  with  but  slight  nutritional  change  of  body,  the 
prognosis  is  usually  not  good  ;  but  so  long  as  functions  such 
as  catamenia  are  absent,  a  prospect  of  improvement  may  be 
entertained,  provided  there  are  no  other  symptoms  to  the 
contrary.  If,  on  the  other  hand,  all  the  functions  of  the 
body  have  been  re-established  and  still  there  is  no  mental 
improvement,  an  unfavourable  prognosis  may  be  expressed,  if 
such  has  not  already  been  made.  The  appearance  of  hair  on 
the  face  of  the  female  usually  is  a  symptom  of  bad  omen. 
Also  persistent  refusal  of  food  for  a  long  period  is  of  grave 
import.  In  conclusion,  it  is  never  well  to  give  a  very  favour- 
able prognosis  in  the  case  of  persons  suffering  from  hypochon- 
driacal melancholia,  as  many  of  these  patients  do  not  recover. 

Pathology  and  Morbid  Anatomy.^ — At  the  present  time  very 
little  is  known  of  the  morbid  changes  which  take  place  in 
the  nervous  system  of  those  afflicted  with  true  melancholia. 
As  already  observed,  depression  may  be  a  symptom  in  many 
diseases  ;  in  each  case  the  changes  will  depend  on  whether 
the  disease  be  organic  or  otherwise.  With  the  so-called 
functional  conditions  it  is  somewhat  difficult  to  discover  what 
exactly  takes  place,  as  death  is  not  common.  We  know  that 
there  are  varying  degrees  of  '  chromatolysis  '  of  the  cortical 
nerve-cells,  as  evidenced  by  the  manner  in  which  the  cell 
takes  various  stains.  There  may  in  severe  cases  be  '  achroma- 
tolysis.'  The  nucleus  may  be  displaced  and  the  dendrons  of 
the  cells  varicose.  In  the  melancholia  of  later  life  arterio- 
sclerotic changes  may  be  observed. 

Several  theories  have  been  advanced  as  to  the  pathology 
of  melancholia,  most  authorities  agreeing  that  the  condition  is 
probably  in  large  measure  due  to  nutritional  changes.  Auto- 
intoxication from  the  alimentary  canal  is  a  theory  which 
steadily  grows  in  favour  ;  and,  when  it  is  remembered  that  even 
temporary  constipation  will  produce  a  feeling  of  depression  in 
most  persons,  this  theory  must  be  deemed  worthy  of  considera- 


MELANCHOLIA  AND  STATES  OF  DEPRESSION  129 

tion.  The  writer  believes  that  altered  blood  states  have  much 
to  do  with  the  development  of  melancholia.  In  all  probability 
toxins  play  an  important  part  in  bringing  about  these  changes^ 
and  ultimately  there  is  usually  a  great  increase  in  the  general 
blood-pressure  (cf.  vaso-motor  disturbances  in  the  chapter  on 
General  Symptomatology).  The  raising  of  the  blood-pressure 
may  be  due  to  the  vitiated  blood  irritating  the  wall  of  the 
vessel.  Whatever  may  be  the  true  pathology  of  melancholia, 
the  increased  blood-pressure  is  a  factor  which  must  not  be 
lost  sight  of ;  for,  if  it  is  not  definitely  a  cause,  it  certainly 
largely  accounts  for  the  feeling  of  depression.  Keference  is 
made  to  the  changes  in  the  blood  in  melancholia  in  the  chapter 
on  General  Symptomatology. 

Treatment. — Many  matters  regarding  the  treatment  of 
melancholia  will  be  found  in  the  special  chapter  on  Treat- 
ment. Here  reference  will  only  be  made  to  those  points 
which  are  especially  connected  with  melanchoHa.  The 
onset  of  this  disorder  is  often  very  insidious,  and  the  early 
symptoms  are  frequently  overlooked  or  misinterpreted.  The 
importance  of  early  treatment  cannot  be  over-estimated,  for 
it  not  only  tends  to  shorten  the  course  of  the  disorder,  but 
lessens  risk  of  suicide. 

It  is  frequently  a  matter  of  no  small  difficulty  to  decide 
when  the  Limits  of  sanity  have  been  passed  in  any  given  case ; 
but  even  if  this  point  is  one  of  perplexity,  there  is  no  reason 
why  the  patient  should  not  be  energetically  treated  at  home. 
Never  allow  a  case  of  melancholia  to  drift  while  you  are 
making  up  your  mind  what  to  do.  The  friends  of  the  patient 
will  not  be  idle,  for  they  will  almost  certainly  aggravate  all 
symptoms  by  continually  telling  the  unfortunate  sufferer  to 
rouse  himself.  If  the  depression  is  marked,  do  not  send  him 
away  to  travel,  as  is  so  commonly  done  by  the  inexperienced  ; 
to  do  so  is  to  court  disaster.  Best  is  the  treatment  that  is 
required.  The  physical  health  must  be  attended  to  ;  it  is 
bad  in  most  cases,  and  it  is  only  by  improving  the  bodily 
condition  that  it  is  possible  to  relieve  the  mind.  If  the  de- 
pression is  acute,  the  patient  must  be  kept  in  bed  for  some 
time,  and  on  no  account  must  any  mental  work  be  permitted. 
The  melancholiac  is  as  unfit  for  work  as  any  one  suffering 
from  a  serious  physical  malady.    His  attention  is   entirely 

9 


r* 


130  PSYCHOLOGICAL  MEDICINE 

preoccupied  with  his  o^vii  thoughts  and  feehngs,  and  he  fails 
to  grasp  business  matters  or  complex  details.  Even  the 
httle  events  of  daily  Hfe  become  exaggerated  into  insur- 
mountable difficulties.  Eemoval  from  home  is  nearly  always 
necessary  ;  for  to  be  in  one's  ordinary  surroundings  and  at  the 
same  time  to  feel  miequal  to  the  performance  of  one's  customary 
duties  is  a  constant  source  of  worry,  and  not  infrequently 
leads  to  delusions  of  unworthiness. 

Again,  the  friends  may  be  almost  as  difficult  to  manage  as  the 
patient.  They  have  an  ingrained  conviction  that  depression  and 
all  its  accompanying  symptoms  are  mider  the  control  of  the 
patient,  and  that  he  can  dismiss  them  hj  an  effort  of  the  will. 
The  unhappy  man  is  already  incHned  to  blame  himself  for  all  his 
shortcomings,  and  the  view  taken  by  his  relatives  only  con- 
firms his  tendency  to  self-accusation.  Suicide  must  be  care- 
fully guarded  against,  and  it  must  not  be  forgotten  that  it  is 
during  the  early  stage  of  depression  that  self-destruction  is 
most  hkely  to  be  attempted.  If  there  is  any  physical  disease 
to  be  discovered,  tliis  must  be  treated.  The  bowels  are 
always  constipated :  a  daily  action  must  be  obtained  by 
enemata  or  aperients.  Younger  patients  do  well  on  salines, 
but  older  persons  should  be  given  a  mixture  such  as 
the  following :  extractum  cascarse  sagradse  Hquidum  half 
a  drachm  and  glycerine  half  a  drachm,  one  teaspoon- 
ful  dose  once  or  twice  a  day  as  required.  If  this  is  not 
sufficient,  a  soap-and-water  enema  must  be  administered 
twice  a  week. 

Most  melanchoHacs  are  very  troublesome  with  their  food 
and  may  refuse  it  altogether.  A  minimum  allowance  should 
be  fixed,  and  if  this  is  not  taken,  forcible  feeding  must 
be  resorted  to.  The  body  weight  must  be  taken  at  regular 
intervals,  and  if  it  is  found  to  be  faUing,  extra  cream  and  eggs 
should  be  added  to  the  dietary.  Sleep  is  always  bad  :  the 
various  methods  for  reheving  this  sjanptom,  which  are  de- 
scribed in  the  chapter  on  Sleeplessness,  may  be  tried.  Sulphonal 
is  not  a  good  drug  for  melanchoUacs,  unless  it  is  possible  to 
keep  the  bowels  freely  open.  Paraldehyde  and  amylene  hydrate 
will  be  found  useful  and  in  some  cases  a  mixtm'e  of  chloral 
hydrate  and  potassium  bromide.  The  daily  exercise,  if  the 
patient  is  allowed  out  of  bed,  must  be  limited.     Many  of  these 


MELANCHOLIA  AND  STATES  OF  DEPRESSION  131 

patients  stand  constantly  in  one  attitude,  a  habit  which  gives 
rise  to  great  oedema  of  the  legs  and  feet.  It  may  become 
necessary  for  such  a  patient  to  be  kept  in  bed  by  a  nurse 
sitting  at  the  bedside. 

In  the  early  stages  of  depression  much  benefit  can  be 
derived  from  the  administration  of  such  drugs  as  erythrol 
tetranitrate.  The  blood-pressure  is  raised  in  melancholia, 
and,  by  artificially  lowering  it,  many  of  the  most  trying  sub- 
jective symptoms  are  relieved  for  the  time  being,  and  in  some 
cases  permanently.  The  action  of  amyl  nitrite  is  good,  but  its 
effect  is  too  evanescent ;  that  of  erjrfchrol  tetranitrate  is  more 
lasting.  The  latter  drug  should  be  given  in  tabloid  form,  half 
a  grain  twice  a  day  for  the  first  three  days,  and  then  by 
progressive  increases  of  half  a  grain  every  three  days  until 
the  dose  reaches  two  or  three  grains  'per  diem.  A  course  of 
Turkish  baths  is  most  beneficial  to  some  melanchoUacs,  as 
►  these  help  in  removing  effete  matter  from  the  system.  Several 
tumblers  of  cold  or  warm  water  should  be  taken  daily,  begin- 
ning with  one  glassful  about  half  an  hour  before  breakfast. 
Stimulant  is  not  necessary  and  should  not  be  given  unless 
symptoms  of  exhaustion  supervene. 

As  convalescence  takes  place  the  patient  should  be  granted 
liberty,  but  it  is  wise  not  to  under-estimate  the  risk  of  suicide. 
Nevertheless,  much  harm  is  often  done  by  keeping  a  patient 
constantly  under  the  eye  of  a  nurse,  and  if  trust  be  put  in  the 
parole  of  a  convalescent  melancholiac,  it  will  rarely  be  abused. 
Get  the  patient  to  promise  that  if  he  ever  has  any  recurrence 
of  the  suicidal  thoughts,  he  wUl  inform  his  nurse  or  some 
other  responsible  person.  When  the  general  health  has  im- 
proved and  the  body  weight  increased,  then,  if  all  the  various 
functions  are  fully  re-established  and  sleep  has  returned,  a 
few  weeks  or  months  of  travel  can  be  recommended.  In  no 
case,  when  avoidable,  should  a  patient  return  to  work  for 
several  months  after  his  illness.  Give  him  careful  directions 
how  he  is  to  live  in  the  future,  so  that  he  may  avoid  recur- 
rences of  depression ;  but  impress  upon  him  if  he  has 
any  threatening  of  an  attack  to  take  advice  early  and 
be  treated  at  once  without  waiting  for  the  development  of 
more  serious  symptoms.  If  the  patient  is  suffering  from  ■ 
the  mixed  form   of  maniacal-depressive  insanity  or  so-called 


182  PSYCHOLOGICAL  MEDICINE 

circular  insanity,  the  relations  must  be  warned  to  watch 
for  the  appearance  of  the  symptoms  of  excitement.  In 
conclusion,  remember  that  serious  depression  is  often  a 
preventable  condition,  and  that  its  early  stages  usually 
respond  to  treatment. 


CHAPTEE  VIII 

STUPOR  AND   CATATONIA 

Stupor 

Stupor  is  a  state  in  which  the  outward  signs  of  mentation 
are  in  abeyance.  It  may  rarely  develop  as  a  primary  disorder, 
-or  it  may  be  secondary  to  some  other  condition.  The  terms 
Primary  and  Acute  Dementia  are  used  by  some  writers  as 
synonyms  for  the  form  of  stupor  known  as  Anergic  Stupor.  By 
almost  universal  custom  the  word  *  dementia  '  is  applied  to 
designate  states  of  permanent  weak-mindedness,  from  whatso- 
ever cause  the  mental  enfeeblement  may  arise.  This  being  the 
case,  it  only  leads  to  unnecessary  confusion  to  make  use  in  any 
way  of  the  word  '  dementia  '  in  connection  with  curable  forms 
of  insanity.  On  these  grounds  the  terms  Primary  Dementia 
or  Acute  Dementia  had  better  not  be  employed. 

etiology. — The  majority  of  cases  of  stupor  occur  in  persons 
under  thirty  years  of  age.  It  is  produced  by  various  stresses, 
and  in  many  cases  it  seems  to  be  closely  connected  with  the 
reproductive  functions.  The  most  potent  causes  are  mental 
and  moral  shocks,  profound  physical  fatigue,  sexual  excess,  and 
attacks  of  acute  excitement. 

Varieties. — The  best  clinical  classification  of  stupor  is  the 
following :  (1)  anergic  stwpor ;  (2)  'post-melancJwlic  stwpor, 
sometimes  known  by  the  term  delusional  stwpor ;  (3)  post- 
maniacal  stwpor  ;  (4)  catatonic  stupor.  In  addition  to  these, 
there  might  be  included  states  of  stupor  associated  with  general 
paralysis  or  epilepsy ;  but  in  these,  though  the  condition 
resembles  stupor,  many  of  the  most  characteristic  symptoms 
are  absent. 

Mental  Symptoms.— It  will  be  more  convenient  to  describe 
the  mental  symptoms  of  the  different  varieties  of  stupor 
under  one  head,   merely  indicating  the  points  of  distinction 


131  PSyCH0L0:5ICAL  MEDICINE 

between  them.  The  mental  symptoms  are  to  a  great  extent 
negative  in  character.  The  patient  stands  or  sits  unoccupied, 
taking  no  apparent  heed  of  his  surroundings.  The  expression 
is  vacant ;  the  eyes  droop  or  stare  ;  the  pupils  are  widely 
dilated ;  saliva  dribbles  from  the  mouth.  The  extremities 
are  cold  and  blue,  and  frequently  oedematous.  Spontaneous 
movements  are  absent.  No  attempt  is  made  to  take  food, 
but  if  it  is  placed  in  the  patient's  mouth  he  may  automatically 
chew  and  swallow  it.  As  a  general  rule  there  is  complete 
mutism.  The  calls  of  nature  are  not  heeded.  At  night  the 
patient  may  remain  quietly  in  bed,  but  sleep  is  usually  very 
deficient. 

There  is  almost  complete  amnesia  in  the  anergic  form  of 
stupor,  so  that  on  recovery  the  patient  remembers  little  or 
nothing  of  his  illness.  The  condition  [  of  memory  is  very- 
different  in  the  post-melancholic  or  delusional  form  of  stujDor, 
for  on  recovery  the  patient  usually  remembers  a  good  deal  of 
what  has  taken  place.  Eor  this  reason  it  is  not  wise  to  discuss 
questions  in  front  of  the  patient  which  are  not  convenient  for 
him  to  hear.  The  receptive  faculties  may  be  very  active, 
whereas  the  executive  may  be  faulty  or  in  abeyance.  The 
emotions .  are  equally  inhibited  :  a  patient  will  hear  of  the 
death  of  his  dearest  relative  without  exhibiting  any  concern. 
Delusions  may  be  present  or  absent ;  in  the  anergic  types 
they  usually  fail  to  be  eHcited,  but  this  failure  may  be  due  to; 
loss  of  memory.  In  post-melancholic  stupor  delusions  may 
be  an  important  symptom,  and  the  patient  frequently  appears 
to  be  dominated  by  some  powerful  idea,  which  occupies  his 
w^hole  attention.  The  sufferer  from  anergic  stupor,  though 
dependent  on  others  to  look  after  him,  is  unresistive  and 
apathetic.  He  can  be  dressed,  fed,  and  attended  to  without 
any  difficulty. 

The  antithesis  of  this  is  to  be  found  in  the  melancholic 
type  of  stupor,  for  here  the  patient  is  very  resistive  to  every- 
thing that  is  done  for  him.  Stuporose  patients  are  seldom 
suicidal  in  the  strict  sense  of  the  word,  but  they  may  commit. 
an  impulsive  act  which  may  result  in  injury  to  themselves  or 
others.  For  this  reason  cases  of  stupor  should  never  be  left 
unattended.  For  weeks  such  a  patient  may  sit  in  the  same 
place   without  making  any  voluntary   movement,   until   the 


STUPOR  135 

nurse  begins  to  look  upon  him  as  bereft  of  mind  and^safe  to 
leave  unattended  for  a  few  minutes  :  she  may  return  to  find 
that  in  her  absence  the  patient  has  smashed  the  window  or 
set  fire  to  himself.  In  the  post-maniacal  type  the  stupor  is 
not  very  profound.  The  condition  is  more  transitory  and 
less  severe  ;  in  short,  the  patient  is  suffering  from  a  stuporose 
state  rather  than  true  stupor.  He  will  react  slowly  to  questions, 
sometimes  rej)eating  them  before  making  a  reply.  Voluntary 
movements  are  performed,  but  only  rarely,  and  they  are  made 
in  a  manner  which  denotes  fatigue. 

Physical  Symptoms. — Most  of  the  bodily  functions  are  dis- 
organised. (1)  Gastro-Intesti7ial. — The  tongue  is  furred,  and 
the  mucous  membrane  of  the  mouth  is  unhealthy.  Saliva  is 
■  not  swallowed  properly  on  account  of  the  diminished  activity 
of  the  pharyngeal  reflexes.  Food  is  not  taken,  and  in  some 
cases,  notably  those  of  melancholic  stupor,  all  nourishment  is 
refused  and  strongly  resisted.  The  bowels  are  constipated, 
not  uncommonly  to  an  extreme  extent,  the  marked  decrease 
in  the  intestinal  secretions  being  largely  responsible  for  this 
condition.  (2)  Circulatory. — The  pulse  is  very  feeble  and 
infrequent ;  the  extremities  are  usually  cold  and  cyanosed, 
and  at  times  oedematous.  (3)  Bes'piratory. — Breathing  is 
slow  and  shallow,  and  auscultation  reveals  a  lessened  respira- 
tory murmur.  (4)  Genito-Urinary. — The  catamenial  periods 
are  absent  as  a  rule.  (5)  Skm  and  A'p'pendages. — -Nutritional 
changes  are  observable  in  the  skin  ;  pustules  and  small  ab- 
scesses may  occur.  The  hair  loses  its  gloss,  and  is  dry,  harsh, 
and  brittle.  The  nails  exhibit  opacities  and  grooves,  due  to 
trophic  changes.  The  body  weight  falls  steadily  during  the 
acute  stage  of  the  disease. 

The  clinical  observations  made  by  Stoddart  support  the 
classification  of  stupor  as  above  arranged.  Melancholic 
stupor,  in  common  with  some  other  forms  of  melancholia,  is 
characterised  by  a  form  of  rigidity  which  mostly  affects  the 
muscles  of  the  trunk  and  the  larger  joints.  In  anergic  stupor 
this  rigidity  is  absent  and  there  is  not  the  condition  known 
as  flexihilitas  cerea.  In  other  cases  of  stupor,  however,  the  latter 
condition  will  be  found  ;  in  it  the  limbs  of  the  patient  can  be 
moulded  and  moved  into  different  positions,  in  which  they  will 
remain  for  some  period  of  time.     Stoddart  has  also  made  careful 


136       ■  PSYCHOLOGICAL  MEDICINE 

investigation  of  the  sensations  in  the  different  forms  of  stupor. 
He  fuids  that  there  is  anaesthesia  covering  an  extensive  area  of 
skin  in  cases  of  anergic  stupor,  and  that  this  loss  of  sensation 
laSij  persist  for  several  weeks  or  months.  Similarly,  in  post- 
maniacal  stupor  there  is  commonly  some  anaesthesia  ;  but  it  is 
usualty  Hmited  to  the  peripheral  ends  of  Hmbs,  being  most 
marked  in  the  forearms  and  hands,  legs  and  feet.  In  these 
cases  the  anaesthesia  is  usually  of  a  transitory  nature  and  may 
last  only  for  a  few  days.  Stoddart  reports  that  he  rarely 
finds  anaesthesia  in  melanchohc  stupor. 

Course. — If  treatment  is  begun  early,  before  any  serious 
nutritional  changes  have  taken  place,  the  progress  may  be 
towards  recovery  in  a  fair  percentage  of  the  anergic  cases  of 
stupor.  The  physical  condition  begins  to  improve  after  a 
few  weeks  of  forced  feeding.  The  various  functions  slowly 
become  re-estabhshed,  and  the  body  weight  increases.  A 
large  number  of  the  patients  with  post-maniacal  stupor  get 
well — stupor  is  one  of  the  stages  on  the  road  to  recovery  from 
mania.  When  a  case  of  stupor  is  taking  an  unfavourable 
course,  the  physical  health  usually  remains  in  an  unsatis- 
factory condition  and  mentally  the  patient  becomes  more  and 
more  degenerate.  The  habits  may  become  very  degraded, 
and  ultimately  a  state  of  profound  dementia  supervenes. 

Diagnosis. — Stupor  must  be  distinguished  from  conditions 
such  as  amentia,  secondary  dementia,  dementia  praecox 
(catatonic  form),  general  paralysis  of  the  insane,  and  cerebral 
tumour.  The  distinction  from  amentia  is  made  from  the 
history  and  the  state  of  physical  health,  which  is  usually 
fairly  good  in  imbeciUty.  In  secondary  dementia  there  is 
alwaj^s  the  history  of  an  acute  attack  of  insanity,  the  general 
nutrition  as  a  rule  is  good,  and  the  sleep  is  not  bad.  In  the 
catatonic  form  of  dementia  praecox  there  are  the  following 
characteristic  symptoms  :  verbigeration,  stereotyped  move- 
ments, and  rigidity,  and  some  authorities  believe  that  plas- 
ticity of  hmbs  also  occurs.  General  paralysis  is  diagnosed  by 
the  presence  of  physical  signs  indicative  of  the  disease.  It  is 
always  wise  carefully  to  examine  all  male  cases  of  stupor  for 
symptoms  of  dementia  paralytica,  as  a  small  percentage  of 
patients  with  that  disease  exhibit  this  form  of  mental  disorder. 
Cerebral  tumour  is   diagnosed   by   the    ordinary    symptoms, 


STUPOR  137 

such  as  headache,  optic  neuritis,  sickness,  or  some  local 
paralysis. 

Prognosis. — As  already  stated,  the  prognosis  is  fairly  good 
in  many  of  the  anergic  and  post-maniacal  cases,  but  the  out- 
look is  not  so  favourable  in  the  melancholic  type.  When  the 
onset  is  rapid,  and  the  treatment  is  begun  early,  the  pro- 
gnosis is  better  than  when  the  stupor  is  of  slow  development. 
There  is  always  a  danger  of  these  patients  developing  phthisis, 
and  they  may  die  from  this  disease. 

Pathology  and  Morbid  Anatomy. — Nothing  is  at  present 
known  as  to  the  pathological  basis  or  morbid  anatomy  of  this 
disorder.  Microscopically  it  is  usual  to  find  nerve-cell  changes 
such  as  chromatolysis  and  achromatolysis.  In  some  cases  a 
general  cerebral  oedema  has  been  observed. 

Treatment. — The  treatment  during  the  early  stages  of  all 
forms  of  stupor  must  be  stimulating  and  supporting.  Food 
must  be  Uberal  and  of  a  nourishing  nature.  Sickness  may 
interfere  with  the  feeding,  in  which  case  the  milk  must  be 
peptonised  and  given  in  small  quantities  very  frequently.  If 
nourishment  is  refused,  artificial  feeding  must  be  resorted  to 
without  delay.  Constipation  should  be  reheved  and  the 
bowels  regulated.  Eetention  of  urine  may  require  reHef. 
In  some  cases  massage  and  passive  exercises  have  proved 
beneficial ;  in  others  cold  and  tepid  shower  baths  may  be 
used  with  advantage,  but  these  must  not  be  continued  if 
there  is  not  a  good  reaction  afterwards.  Eest  in  bed  is  usually 
necessary  in  those  cases  where  the  circulation  is  very  bad 
and  in  which  there  is  swelling  of  the  feet  and  legs.  The  nurse 
should  be  cautioned  against  leaving  the  patient  unattended, 
otherwise  an  accident  may  occur  as  a  result  of  some  impulsive 
act.  It  is  a  wise  precaution  to  have  the  patient's  temperature 
taken  night  and  morning,  as  fever  may  be  the  first  indication 
of  early  phthisis.  Easterbrook,  in  his  valuable  paper  on 
Organo-Therapeutics,^  reports  that  good  results  followed  the 
administration  of  thyroid  gland  in  several  stuporose  cases 
under  his  care.  The  experience  of  the  writer  does  not  confirm 
this  further  than  the  fact  that  a  patient  with  stupor  after  taking 
thyroid  for  a  week  frequently  becomes  more  active.  If  thyroid 
is  given,  the  body  weight  and  general  health  of  the  patient 
^  The  Journal  of  Mental  Science,  1900. 


138  PSYCHOLOGICAL  MEDICINE 

must  be  carefully  watched,  as  serious  emaciation  may  take 
place. 

Catatonia 

Catatonia  is  a  disease  or,  to  speak  more  accm'ately,  a  group 
of  symptoms,  which  was  first  observed  and  described  by 
Kahlbaum  in  1874.  Kraepelin  treats  catatonia  as  a  special 
variety  of  dementia  prascox.  The  ^T.iter  has  seen  several 
cases  of  catatonia  in  persons  well  past  middle  age,  and  for 
this  reason  caimot  regard  it  as  merely  a  type  of  precocious 
dementia.  The  bounds  of  dementia  praecox  must  be  defined, 
otherwise  the  term  is  useless,  for  to  say  that  a  patient  is  suffering 
from  dementia  praecox  when  he  is  within  a  few  years  of  senility 
is  clearly  a  misuse  of  language.  The  answer  may  be  that 
there  are  two  diseases  closely  resembling  each  other  and  yet 
in  reality  different  ;  and  that  one  is  associated  with  adolescence, 
while  the  other  is  common  to  other  periods  of  hfe.  But  if 
this  is  the  case,  the  disorders  appear  to  be  indistinguishable 
clinically  and  must  at  present  be  treated  as  one  and  the  same. 

Mental  Symptoms. — The  disorder  not  uncommonly  begins 
with  a  period  of  depression,  lasting  from  a  few  days  to  several 
weeks.  Dm'ing  this  time  the  physical  health  of  the  patient 
fails  ;  he  sleeps  badly,  and  is  disinclined  to  take  food.  Delu- 
sions of  almost  any  kind  may  appear,  and  sensory  disturb- 
ances of  the  natm'e  of  hallucinations  are  at  times  prominent. 
Following  this  depression,  there  may  be  a  stage  of  maniacal 
excitement  or  agitated  melanchoha.  The  patient  becomes 
restless  and  is  apprehensive  of  some  impending  harm.  Very 
soon  the  condition  becomes  one  of  stupor.  The  patient  stands 
or  sits  without  showing  any  signs  of  spontaneous  movement. 
This  symptom  is  spoken  of  as  the  symptom  of  negativism. 
Passive  movements  are  met  by  a  powerful  resistance.  The 
patient  resists  everything  that  is  done  for  him.  If  this  re- 
sistance can  be  overcome,  a  limb  will  frequently  remain  in  the 
position  in  which  it  has  been  left  by  the  operator.  This  rigid 
immobility  may  be  broken  fi'om  time  to  time  by  movements 
incessantly  repeated  in  an  automatic  maimer,  to  which  symptom 
the  term  stereotyped  viovevients  has  been  given.  The  muscles 
are  in  a  very  rigid  state,  and  the  patient  may  assume  most. 
uncomfortable  positions.     The  jaws  may  be  tightly  clenched. 


CATATONIA  139 

with  the  head  either  thrown  backwards  or  drawn  forwards. 
The  eyes  are  either  staring,  or  the  eyehds  are  tightly  closed. 
The  body  is  usually  somewhat  flexed  ;  the  limbs  are  rigid, 
with  the  forearms  at  right  angles  to  the  arm,  and  the  hands 
clenched.  The  rigidity  is  greatest  in  the  large  joints.  If 
the  patient  walks  at  all,  the  gait  is  slow  and  hesitating. 

Mutism  is  another  prominent  symptom  ;  but  this  mutism 
may  be  broken  by  periods  during  which  the  person  repeats 
words  or  phrases  in  a  monotonous  or  automatic  manner  (verbi- 
geration). The  sounds  are  not  always  recognisable  words, 
and  occasionally  they  are  inarticulate  nonsense.  Many 
of  the  other  symptoms  are  those  common  to  stupor.  The 
muscular  tension  is  not  always  marked,  and  at  times  the 
limbs  can  be  easUy  moved  about  into  any  position,  in  which 
they  remain ;  the  term  flexihilitas  cerea  is  used  to  describe 
this  condition.  At  times  the  patient  will  react  to  questions, 
usually  by  a  repetition  of  the  words  which  formed  the  ques- 
tion {echolalia).  Sudden  excitement  may  supervene  at  any 
time  and  may  last  for  several  days  or  weeks.  In  addition 
to  the  maniacal  symptoms,  stereotyped  movements  and  verbi- 
geration may  be  observed. 

Physical  Symptoms. — The  physical  state  of  the  patient  in 
many  ways  closely  resembles  that  akeady  described  under 
Stupor,  except  for  the  peculiar  muscular  rigidity  above  referred 
to.  Trophic  changes  take  place  all  over  the  body.  Vaso- 
motor disturbances  are  noticeable.  The  respiration  is  slow 
and  shallow,  and  in  this  way  favours  the  development  of 
phthisis.  Food  is  refused  or  eaten  ravenously ;  resort  to 
artificial  feeding  may  be  necessary.  The  bowels  are  consti- 
pated, and  there  is  amenorrhoea  in  the  female.  The  general 
health  always  suffers,  and  the  weight  falls.  Convulsive 
seizures  have  been  reported  in  certain  isolated  cases. 

Com^se. — The  course,  in  many  cases,  is  steadily  towards 
dementia.  The  stupor,  alternating  with  attacks  of  excitement, 
may  last  for  several  years.  When  the  patient  becomes  defi- 
nitely weak-minded,  the  physical  health  not  uncommonly 
improves  and  the  body  weight  increases.  Food  is  taken  freely, 
but  the  patient  remains  careless  in  his  dress  and  may  be 
degraded  in  his  habits.  In  a  small  percentage  of  cases  the 
symptoms  clear  up  and  the  patient  recovers. 


140  PSYCHOLOGICAL  MEDICINE 

Prognosis. — The  prognosis  is  usually  unfavourable,  but  in 
a  small  percentage  of  cases  recovery  takes  place. 

Pathology  and  Morbid  Anatomy.^ — Nothing  is  known  as  to 
the  pathological  changes  which  produce  this  disease. 

Treatment. — The  treatment  is  practically  the  same  as  that 
of  stupor. 


141 


CHAPTEE  IX 

CHRONIC  DELUSIONAL  INSANITY  (PARANOIA) 

Some  doubt  has  been  felt  by  the  writer  as  to  the  most  suitable 
title  to  this  chapter.     In  some  ways  Paranoia  is  the  better 
term,  but  unhappily  the  word  has  been  used  by  various  authors 
to  denote  widely  different  diseases,  and  in  consequence  much 
confusion  has  resulted.     Percy  Smith  took  Paranoia   as  the 
subject  for  his  presidential  address  ^  before  the  annual  meet- 
ing of  the  Medico-Psychological  Association  in  July  1904,  and 
made  an  exhaustive  review  of  the  disorder.     After  reciting 
the  various  views  on  paranoia  held  by  English  and  Continental 
writers,  he  said  :    '  I  think  I  have  said  enough  to  show  that 
there  is  no  common  agreement  as  to  the  connotation  of  "  para- 
noia," even  in  the  country  of  its  origin  ;  that  by  some  authors 
groups  of  cases  are  included   under  this  term  which  others 
hold  to  be  entirely  outside  it,  and  that  the  doctrine  of  primary 
intellectual  disorder,   apart   from   the   element  of  feeling   or 
"  affect,"  has  of  late  received  rude  shocks,  and   that  it   is 
tottering  to  its  fall.     I  have  always  taught  students  that  in 
examining  any  case  of  mental  disorder  it  is  entirely  erroneous 
to  omit  to  examine  all  the  functions  of  mind,  feeling,  knowing, 
and  willing ;    that  the  mind  is  not  divided  into  water-tight 
compartments  ;  and  that  in  taking  the  history  of  any  case  it  is 
most  important  not  to  accept  without  close  inquiry  the  account 
given  by  relatives  of  the  mode  of  onset  and  order  of  appear- 
ance of  symptoms.     In  my  opinion  the  separation  of  primary 
affective  from  primary  intellectual  disorders  is  purely  artificial, 
and  just  as  in  mania  and  melancholia  the  affective  state  is 
not  the  sole  factor,  so  in  paranoia  the  affective  side  cannot  be 
ignored.'     He  sums  up  his  views  as  follows  : 

^  Presidential  Address,  The  Journal  of  Mental  Science,  October  1904. 


142  PSYCHOLOGICAL  MEDICINE 

'  1.  The  term  "  paranoia  "  is  useful  if  it  be  limited  to  cases 
of  chronic  delusional  insanity  in  which  there  are  organised 
and  systematised  delusions,  whether  of  persecution  or  exalta- 
tion, and  whether  these  run  separately,  concurrently,  or  by 
transformation  from  persecution  to  exaltation,  and  whether 
the  disorder  originates  in  childhood  and  youth  (originare 
paranoia)  or  later  in  life  (tardive  paranoia),  and  whether 
associated  with  heredity  or  not. 

'  2.  In  all  these  cases  the  importance  of  the  affective  ele- 
ment of  mind  must  not  be  ignored,  and  it  is  erroneous  to  use 
the  term  "  paranoia  "  as  implying  primary  intellectual  disorder 
to  the  exclusion  of,  or  prior  to,  disorder  of  "  Affect." 

'  3.  Allowing  that  there  are  acute  cases  in  which  delusions 
appear  to  be  organised  and  systematised,  and  yet  in  which 
recovery  appears  to  take  place,  many  of  these  are  merely  the 
initial  phase  of  chronic  delusional  insanity  with  a  remission 
of  symptoms. 

'  4.  If  the  incubus  of  the  idea  of  primary  intellectual  dis- 
order be  got  rid  of,  there  is  no  difficulty  in  recognising  that 
some  cases  of  paranoia  may  begin  with  an  acute  functional 
mental  disorder  of  the  nature  of  melancholia  or  mania  (as  is 
indeed  recognised  even  by  those  who  take  the  primary  intel- 
lectual view),  or  even  may  follow  a  delirious  or  confusional 
state. 

'  5.  With  this  exception,  acute  confusional  insanity  (acute 
Verwirrtheit)  and  acute  delirious  states  (acute  delirium,  col- 
lapse dehrium,  Erschopfungsdelirium)  should  be  regarded 
setiologically  and  clinically,  and  from  the  point  of  view  of 
diagnosis  and  prognosis,  as  entirely  apart  from  paranoia  or 
chronic  delusional  insanity. 

'  6.  Mercier's  term  "  fixed  delusion  "  should  be  used  for 
states  secondary  to  acute  forms  of  insanity,  where  the  persisting 
delusions  are  not  organised  or  progressively  systematised. 

'  7.  With  regard  to  terminal  dementia  in  paranoia,  it  is 
trying  to  prove  too  much  to  say,  as  some  authorities  do,  that 
dementia  does  not  even  supervene  in  this  condition  ;  and  I 
think  that  Kraepelin's  action  in  removing  a  large  group  of 
cases  in  which  terminal  weak-mindedness  occurs  from  the 
domain  of  paranoia  to  that  of  dementia  praecox  is  open  to 
question.     There  seems   to   me  a  possibility   that   dementia 


,.  CHRONIC  DELUSIONAL  INSANITY  143 

prsecox,  with  its  hebephrenic,  catatonic,  and  paranoid  forms, 
may  become  the  new  miiversal  disease  (Universalkrankheit) 
into  which  large  numbers  of  cases  may  be  thrown,  and  which 
will  give  rise  at  no  distant  date  to  as  much  discussion  as  has 
attended  paranoia.' 

The  opinion  held  by  Percy  Smith,  and  so  clearly  formulated 
in  the  above  paragraphs,  is  no  doubt  similar  to  that  enter- 
tained on  this  subject  by  many  English  physicians.  The 
writer  agrees  with  a  great  deal  that  Percy  Smith  has  stated  ; 
one  point  that  he  would  contest  is  that  in  which  '  the 
doctrine  of  primary  intellectual  disorder  '  is  condemned.  Few 
persons  would  disagree  with  him  when  he  states  that  '  it  is 
erroneous  to  use  the  term  "  paranoia  "  as  implying  primary 
.  intellectual  disorder  to  the  exclusion  of,  or  prior  to,  disorder  of 
"  Affect."  '  But  granted  that  it  is  impossible  to  get  a  disorder 
of  emotion  without  some  disorder  of  ideation,  or  a  disturbance 
of  intellect  without  some  accompanying  disturbance  of  the 
'  affections,'  surely  it  may  be  possible,  or  even  probable,  that 
some  disorders  may  begin  with  a  primary  intellectual  disorder 
in  which  the  accompanying  emotional  disturbances  are  so  slight 
as  to  be  almost  unrecognisable  for  a  time.  In  the  same  way 
some  patients  with  depression  may  have  so  sHght  a  correlative 
intellectual  change  that  even  the  keenest  observer  fails  to 
detect  it.  No  doubt  the  changes  are  present,  but  in  such  an 
unequal  proportion  that  clinically  the  one  may  be  considered 
as  primary  to  the  other.  The  whole  course  of  the  disease 
bears  this  out. 

Further,  although  our  knowledge  of  the  locaUsation  of  the 
various  functions  of  the  brain  is  very  elementary,  yet  on  a 
friori  grounds  it  is  probable  that  the  emotions  proceed  from 
an  area  different  from  those  devoted  to  memory  or  ideation. 
The  stability  of  one  portion  of  the  brain  may  be  greater  than 
another,  and  consequently  one  may  be  affected  before  the 
other.  The  association-fibres  are  less  stable  than  the  projec- 
Ition  fibres,  and  the  former  frequently  show  degeneration  when 
•little  change  can  be  detected  in  the  latter.  The  writer  fully 
agrees  with  Percy  Smith  when  he  states  that  '  in  taking  the 
history  of  any  case  it  is  most  important  not  to  accept  without 
close  inquiry  the  account  given  by  relatives  of  the  mode  of 
onset  and  order  of  appearance  of  symptoms.'    Much  may  be 


144  PSYCHOLOGICAL  MEDICINE 

learned  from  a  correct  history,  and  it  is  often  an  invaluable 
aid  to  accurate  prognosis.  For  example,  those  mental  dis- 
orders which  exhibit  early  intellectual  changes  with  little 
emotional  distm'bance  are  less  likely  to  recover  than  the  early 
and  marked  disorders  in  which  the  intellectual  powers  are  but 
slightly  deranged. 

The  cardinal  featm^e  of  this  disorder  is  the  tendency  to  fixed 
systematised  delusions.  Delusions  occur  in  most  forms  of 
mental  disorder,  but  frequently  they  are  an  outcome  of  the 
insanity  and  constantly  alter  with  the  changes  in  the  various 
mental  phases  through  which  the  malady  may  pass.  In 
these  cases  the  delusions  are  the  explanation  the  patient  gives 
of  his  altered  feelings  and  thoughts.  In  paranoia  it  is  different. 
Through  many  months  and  years  the  delusions  are  being 
slowly  woven  and  systematised  ;  the  mental  change  is  so 
insidious  that  the  patient's  friends  look  on  and  scarcely  heed 
what  is  taking  place.  Kevertheless,  during  the  whole  time 
the  individual  has  been  learning  to  accommodate  his  hfe  to 
the  new  conditions.  Thus  in  chronic  delusional  insanity  the 
delusions  form  the  very  essence  of  the  mental  disorder.  It  is 
for  this  reason  that  such  great  difficulty  is  sometimes  found  in 
certifying  these  patients,  in  spite  of  feeling  strongly  convinced 
that  they  are  insane.  With  care  the  paranoiac  can  retain  his 
freedom  for  a  long  time  ;  he  has  no  severe  emotional  disturb- 
ances such  as  are  seen  in  mania  or  melanchoHa,  and  slight 
vagaries  of  conduct  are  frequently  all  that  can  be  detected. 
He  is  cautious  in  conversation  and  wiU  fence  with  questions, 
for  he  usually  treats  everyone  with  suspicion. 

To  return  :  Older  authors  were  wont  to  use  the  term  Mono- 
mania to  designate  this  malady.  There  were  three  main 
varieties  :  (1)  Monomania  of  grandeur ;  (2)  7nonoma7iia  of 
suspicion  ;  and  (3)  monomania  of  unseen  agency  (electricity, 
hypnotism,  etc.).  These  terms  have  been  disused  for  some 
time,  as  they  are  inaccurate.  Clinically  it  is  very  rare  to 
find  true  monomania,  whereas  it  is  common  to  find  several 
delusions.  The  patient  who  believes  himself  to  be  an  em- 
peror not  uncommonly  has  delusions  of  persecution  and 
unseen  agency  as  well.  As  has  been  already  observed,  the 
emotions  are  not  severely  disordered  ;  such  disturbances  as 
occur  are  merely  in  keeping  with  the  delusions.  The  judg- 
ment, however,  may  be  seriously  impaired  by  the  delusions. 


CHRONIC  DELUSIONAL  INSANITY  145 

The  principal  characteristic  of  chronic  delusional  insanity  is 
the  gradual  systematisation  of  the  delusions  over  a  long  period, 
until  ultimately  they  become  fixed. 

etiology. — Chronic  delusional  insanity  is  rather  more 
commonly  found  in  men  than  in  women  ;  it  is  an  insanity  of 
adult  hfe.  Most  patients  have  an  insane  inheritance.  Sexual 
perversions  and  excesses  are  found  in  a  fair  proportion  of  cases. 
The  solitary  schoolboy  is  the  potential  paranoiac  ;  he  avoids 
the  society  of  his  fellows,  and  slowly  weaves  the  theory  that 
they  do  not  care  to  associate  with  him.  He  fosters  these  ideas, 
until  all  his  actions  and  thoughts  are  coloured  by  them. 

Chronic  delusional  insanity  may  appear  to  be  the  outcome  of 
a  highly  egotistical  mental  constitution,  though  in  all  probabiHty 
the  egotism  is  in  reality  symptomatic  from  the  first.  Conceit 
may  be  carried  to  such  an  extent  as  to  become  pathological. 
A  sohtary  life  is  also  very  prone  to  produce  delusional  states. 

Varieties. — Many  attempts  have  been  made  to  classify 
paranoia.  None  are  quite  satisfactory,  as  either  they  include 
other  forms  of  mental  disorder  or  they  fail  to  embrace  cases 
that  clearly  ought  to  be  included.  Ziehen  suggested  that  the 
cases  might  be  divided  into  two  large  groups,  according  to 
the  predominance  either  of  the  delusions  or  hallucinations  : 

(1)  Paranoia  siviplex  acuta  and  Paranoia  sim'plex  clironica  ; 

(2)  Paranoia  hallucinatoria  acuta  and  Paranoia  ]ialluci7ia- 
toria  chronica.  This  classification  is  umiecessarily  complex, 
the  presence  of  hallucinations,  in  almost  every  case,  being 
merely  a  question  of  time,  and  there  seems  to  be  no  need 
for  any  distinction  between  acute  and  chronic.  Krafft-Ebing 
has  a  somewhat  better  arrangement.  He  divides  paranoiacs 
into  (1)  those  who  developed  symptoms  in  early  childhood  or 
before  puberty  ;  and  (2)  those  who  acquired  paranoia  between 
the  periods  of  puberty  and  old  age.  Amadei  and  Tonnini 
separated  paranoia  into  two  great  classes,  viz.  :  (1)  Degenera- 
tive ;  (2)  Psycho-Neurotic.  AVith  the  former  there  is  always 
an  insane  inheritance.  The  degenerative  class  is  subdivided 
into  (a)  cases  in  which  there  is  an  early  exhibition  of  abnormal 
symptoms  ;  {h)  cases  in  which  there  is  a  gradual  development 
of  mental  disorder.  In  the  case  of  psycho-neurotic  paranoia, 
the  original  development  is  slow,  but  a  more  rapid  course  is 
afterwards  run  than  is  the  case  in  the  degenerative  class  ; 
furthermore,  psycho-neurotic  paranoia  may  end  in  recovery. 

10 


146  PSYCHOLOGICAL  MEPICINE 

Mental  Symptoms. — The  first  stage  of  this  form  of  mental 
disorder  may  extend,  over  many  years  and  has  been  called 
the  prodromal  or  incubation  period.  All  symptoms  are  very 
indefinite.  The  safferer  may  often  be  thought  to  be  morbidly 
shy  or  suspicious  by  nature,  but  no  one  would  suggest  that 
he  is  insane.  Solitude  is  sought,  through  the  patient's  belief 
that  others  shun  his  society  or  make  him  an  object  of  ridicule. 
In  a  short  time,  as  the  disease  further  develops,  the  stage 
which  has  been  called  by  Falret  and  Eitti  the  '  period  of  insane 
misinterpretation '  is  reached.  The  patient  now  explains 
everything  that  takes  place.  Ideas  of  persecution  begin  to 
formulate,  but  otherwise  delusions  remain  vague  and  indefinite. 
He  becomes  more  and  more  introspective  and  shows  a  marked 
tendency  to  misinterpret  all  his  sensations.  He  becomes 
increasingly  suspicious,  and  if  he  sees  a  group  of  persons  in 
conversation,  will  imagine  that  he  is  the  topic  of  that  conversa- 
tion. A  chance  cough  may  be  construed  into  an  insult.  The 
movements  of  others  are  clothed  with  some  hidden  meaning. 
He  mistrusts  his  relatives  and  believes  that  they  are  in  league 
with  others  to  annoy  him.  In  the  streets  every  person  seems 
to  look  at  him,  to  know  him,  and  to  be  passing  remarks  about 
him.  He  sees  signs  and  hints  everywhere.  He  reads  sneers 
and  scorn  in  every  face.  He  notes  everything,  and  nothing 
seems  too  trivial  for  his  attention.  He  may  suspect  that 
jDoison  is  being  j)ut  in  his  food  and  carefully  examine  it  for 
signs  of  treachery.  His  judgment  on  some  points  is  so  biased 
that  he  will  in  explanation  prefer  the  far-fetched  to  the  obvious, 
if  only  it  supports  his  beliefs. 

The  actions  of  such  a  person  are  often  more  instructive 
than  his  conversation,  from  which,  as  a  rule,  but  little  can  be 
gleaned.  It  is  in  actions  that  a  suspicious  person  shows  his 
suspicion.  He  will  only  take  food  prepared  by  himself  ;  the 
manner  of  his  replies  to  questions  rather  than  their  substance 
will  indicate  his  state  of  mind  ;  he  will  prefer  solitude  to  the 
company  of  others.  Sometimes  a  patient  will  resign  an 
appointment  or  give  up  an  old-established  business,  and  try 
to  start  in  some  place  where  he  feels  that  he  is  not  known. 
He  will,  however,  never  settle  down  for  long,  for  soon  he  finds 
fresh  proof  that  his  enemies  have  traced  his  whereabouts  and 
are  conspiring  against  him.     In  this  way  a  person  may  move 


CHRONIC  DELUSIONAL  INSANITY  147 

his  abode  many  times  a  year.  Suicide  may  be  sought  as  a 
means  of  escape  from  all  the  annoyances.  Sometimes  resent- 
ment may  lead  to  retaliation,^when  blows  may  be  struck  or 
greater  violence  be  done. 

The  progress  of  the  mental  disorder  may  stop  altogether 
at  this  stage,  but  at  times  hallucinations  and  various  sensory 
disorders  appear  and  lend  further  support  to  the  slowly 
organising  delusions.  Where  formerly  he  saw  a  group  of 
persons  and  felt  convinced  that  he  was  the  topic  of  their  con- 
versation, he  now  definitely  hears  their  insults.  At  first  he 
will  probably  only  catch  names  and  abusive  terms  used, 
but  later  he  may  hear  long  sentences.  There  may  be  disorders 
of  all  the  special  senses,  but  hallucinations  and  illusions  of 
hearing  and  sight  are  the  most  frequent.  .  The  patient  sees 
the  poison  that  is  put  into  his  food  ;  he  smells  the  foul  gases 
that  are  forced  through  the  walls  of  his  apartment ;  he  hears 
the  hum  of  the  electric  apparatus  and  feels  the  shocks.  A 
common  belief  held  by  patients  of  this  class  is  that  others 
can  read  their  thoughts,  which  either  '  take  shape  '  or  are 
*  echoed  loudly.'  Patients  with  these  ideas  will  usually  shun 
society.  The  advance  of  science  makes  it  increasingly  difficult 
to  disabuse  a  patient's  mind  of  beliefs  of  this  kind  ;  he  will 
argue  that  just  as  the  Marconi  apparatus  transmits  and  re- 
ceives vibrations  of  the  aether,  so  it  is  possible  for  his  nervous 
system  to  do  the  same.  Similarly,  to  an  objection  that  others 
do  not  hear  all  the  voices  and  sounds,  he  will  retort  that  every 
brain  is  not  tuned  alike  for  the  reception  of  vibration.  A 
common  form  of  delusion  is  that  some  one  is  tampering  with 
his  genital  organs.  Female  patients  often  make  charges 
that  they  have  been  outraged.  Hallucinations  of  smell  are 
said  by  some  authorities  to  be  frequently  associated  with 
delusions  of  a  sexual  nature. 

The  paranoiac  is  often  wonderfully  ingenious  in  the  way 
that  he  explains  his  symptoms  and  the  various  phenomena 
which  he  beheves  to  be  the  product  of  unseen  agencies.  He 
will  concoct  extraordinary  theories,  and  describe  in  detail 
the  complicated  apparatus  by  which  these  deeds  of  villainy 
are  done  ;  and  he  does  not  hesitate  to  ascribe  to  his  perse- 
cutors almost  superhuman  powers  of  invention.  No  idea 
seems  to  him  to  be  absurd,  however  fantastic  it  may  be ; 


148  PSYCHOLOGICAL  MEDICINE 

all  his  thoughts  and  energies  are  dii'ected  towards  collect- 
ing evidence  in  support  of  his  beliefs.  About  this  time  he 
usually  comes  to  some  conclusion  as  to  who  are  his  persecutors. 
Eeligious  sects,  such  as  the  Jesuits  and  Koman  Catholics,  are 
frequently  suspected  ;  Freemasons  or  the  Government,  among 
others,  are  denounced  as  the  originators  of  the  annoyance. 
At  times  a  particular  person  may  be  named  as  the  arch- 
conspirator,  and  where  this  occurs,  there  is  a  danger  of 
retaliatory  violence.  The  measures  taken  by  a  patient  to 
rid  himself  of  his  persecutors  depend  largely  on  his  own  mental 
constitution.  He  may  fly  from  them,  commit  suicide,  resort 
to  violence,  seek  protection  from  the  police,  or  take  civil  action 
in  the  courts. 

Sometimes  a  patient  will  seek  audience  from  the  King  or 
Prime  Minister,  in  order  to  recount  his  troubles  and  gain 
some  redress  from  his  persecutors.  The  emotional  state  is 
frequently  one  of  indifference  and  in  spite  of  his  troubles  the 
sufferer  does  not  always  become  depressed.  Outbursts  of 
excitement  are  not  uncommon  in  young  paranoiacs.  The 
memory  is  usually  good,  and  on  some  points  excellent,  but 
with  the  passage  of  time  and  the  constant  direction  of  atten- 
tion to  the  particular  subjects  of  delusion,  it  is  found  to 
become  somewhat  defective.  It  is  interesting  to  note  how 
a  patient  will  recall  incidents  of  long  ago  and  read  into  them 
quite  a  new  construction.  He  will  see  evidences  of  persecu- 
tion in  the  former  behaviour  of  his  colleagues.  He  will  tell 
you  that  he  now  quite  understands  what  was  meant  by  this  or 
that  event,  though  at  the  time  he  was  foolish  enough  not  to 
see  it  in  its  true  light. 

The  patient  with  chronic  delusional  insanity  is,  as  a  general 
rule,  perfectly  capable  of  advising  others,  and  often  for  a 
long  tim.e  the  reasoning  power  is  quite  good  for  subjects  which 
do  not  affect  him.  The  delusions  may  be  of  such  a  limited 
nature  that  they  scarcely  interfere  with  the  performance  of 
ordinary  business  duties,  though  this  is  by  no  means  common  ; 
and,  further,  a  man  with  delusional  insanity  may  have  a 
*  disposing  mind  '  and  be  capable  of  making  a  will.  It  is 
the  nature  and  the  class  of  the  delusions  that  decide  the 
question  of  capability  to  transact  business. 

As   has   been  pointed   out,   delusions   of  persecution  may 


CHRONIC  DELUSIONAL  INSANITY  149 

persist  throughout  Hfe,  or  they  may  become  replaced  or  asso- 
ciated with  dekisions  of  grandeur.  The  man  who  believes 
that  when  he  goes  into  the  streets  he  is  at  once  the  object 
of  interest  to  every  passer-by,  and  that  all  men  seem  to  know 
about  his  thoughts  and  business,  may  ultimately  conclude 
that  he  is  in  reality  some  great  personage.  He  may  say  to 
himself,  '  Why  does  the  world  at  large  take  such  a  great 
interest  in  me  ? '  '  Why  do  the  Jesuits  seek  my  life  ? ' 
'  Why  do  the  police  watch  me  wherever  I  go  ?  It  surely  must 
mean  that  I  am  a  prince  or  a  king.'  Hallucinations  may  tell 
him  that  he  is  of  royal  blood.  Some  patients  will  tell  you 
that  they  have  heard  God's  voice  saying  that  they  are 
prophets,  and  must  save  the  world.  They  usually  look  upon 
any  persecutions  that  they  may  have  to  suffer  as  the  natural 
outcome  of  their  great  position,  and  fully  expect  to  find  the 
world  at  enmity  with  them. 

Not  uncommonly,  patients  of  this  class  take  precautions 
against  apprehended  violence.  The  writer  has  known  cases 
in  which  armour  has  been  worn  under  the  clothing  for 
protection. 

An  exalted  person  conducts  himself  as  he  considers  his 
station  warrants.  Some  patients  refuse  to  dress  or  undress 
themselves  and  will  treat  their  fellow-patients  in  a  haughty 
and  overbearing  manner.  They  consider  it  incumbent  on 
them  to  find  fault  with,  and  swear  at,  the  nurse.  They 
will  tell  you  that  the  newspapers  constantly  refer  to  them, 
and  that  the  Court  and  Parliament  are  interested  in  them. 
Some  of  these  persons  are  intensely  jealous  ;  there  may  also 
be  a  strong  element  of  eroticism  in  their  condition.  A  proud 
paranoiac  may  offer  his  hand  in  marriage  to  some  actress  or 
public  personage,  and  if  he  receives  a  rebuff,  may  shoot 
either  the  lady  in  question  or  anyone  he  supposes  to  be  her 
lover.  It  should  never  be  forgotten  that  it  is  the  sufferer 
from  delusional  insanity  who,  above  all  others,  is  likely  to 
commit  acts  of  violence.  He  is  cunning  and  scheming, 
capable  both  of  devising  a  plan  and  choosing  the  best  moment 
for  its  effective  execution. 

When  the  delusions  have  become  organised,  it  is  nearly 
always  necessary  for  a  person  to  be  confined  in  an  asylum, 
if  he  has  not  been  certified  as  insane  long  before.    Individuals 


150  PSYCHOLOGICAL  MEDICINE 

in  this  state  are  constantly  interfering  with  society  and  are 
often  a  source  of  danger  to  tliemselves  or  others.  Patients 
with  a  disposition  to  htigation  may  get  into  tlie  hands  of 
soHcitors  of  doubtful  honesty,  with  the  result  that  their  pro- 
perty is  squandered  in  useless  htigation,  which  no  honest 
adviser  would  have,  permitted.  Many  instances  of  the  kind 
have  been  seen  in  our  courts  of  justice ;  public  time  is 
wasted,  and  the  means  which  should  have  maintained  the 
patient  in  comfort  pass  into  the  pocket  of  an  unscrupulous 
attorney.  Undoubtedly  the  paranoiac  is  not  always  an  easy 
person  to  diagnose  as  insane  ;  but  it  is  extraordinary  how 
slow  the  lay  mind  is  in  detecting  mental  disorder  of  this 
type.  In  consequence  the  patient  is  often  far  more  wronged 
by  those  who  seek  or  purport  to  befriend  him  than  by  any 
petty  grievances  or  insults  which  are  alleged  against  him,  even 
upon  the  assumption  that  these  were  true.  Most  commonly 
they  are  so  transparently  frivolous  and  so  unsupported  by 
evidence  that  the  most  average  intelHgence  should  perceive 
that  they  are  the  product  of  a  disordered  brain.  Cases  of  this 
type  may  make  unfounded  charges  of  unfaithfulness  against 
the  wife  or  husband,  as  the  case  may  be. 

There  is  another  medico-legal  aspect  to  these  cases.  Many 
of  the  younger  paranoiacs  are  sexual  perverts,  and  they  are 
constantly  placing  themselves  within  the  reach  of  the  law  by 
committing  some  criminal  act.  Some  of  these  patients  may 
experience  a  change  of  personality.  For  example,  a  man  may 
ape  the  female  both  as  regards  manners  and  dress.  Others 
will  seek  friends  only  among  members  of  their  own  sex, 
and  homo-sexual  tendencies  may  ultimately  result.  Social 
rank  is  of  no  consequence  with  them  ;  they  will  associate 
with  men  far  inferior  to  them  in  station.  These  persons  are 
frequently  highly  imaginative,  and  may  spend  much  of  their 
time  ^Titing  poetry.  They  are  inclined  to  be  religiose  and 
emotional,  and  at  times  effeminate.  They  are  very  unrehable, 
and  many  are  totally  incapable  of  earning  a  hving,  the  con- 
centration of  attention  necessary  for  work  being  interfered 
with  by  flights  of  imagination.  Some  will  do  needlework 
or  engage  themselves  upon  other  forms  of  occupation  usu- 
ally done  by  women.  Homo-sexual  tendencies  often  take 
a     long    time    to    develop,    as    most    persons    will    at    first 


'^       CHRONIC  DELUSIONAL  INSANITY  151 

fight  against  the  impulses,  but  even  if  they  are  established, 
careful  and  judicious  treatment  may  greatly  help  the 
patient. 

Again,  the  paranoiac  is  deficient  in  control,  and  is  therefore 
readily  mfluenced.  He  may  be  highly  sesthetic  in  his  tastes, 
but  he  lacks  ballast  and  frequently  becomes  the  dupe  of 
unprincipled  persons  :  he  may  become  wildly  extravagant. 
Spiritualism  and  other  occult  sciences  are  subjects  which 
greatly  appeal  to  the  chronic  delusional  patient.  They  attract 
his  imaginative  temperament  and  appeal  to  him  as  the  true 
explanation  of  the  extraordinary  phenomena  of  his  hie.  The 
sense  of  mystery  is  often  well  developed,  and  may  become  the 
most  powerful  factor  in  the  lives  of  these  patients.  Eeference 
has  already  been  made  to  the  tendency  of  delusional  patients 
to  imagine  that  everything  that  happens  about  them  has  a 
special  reference  to  themselves.  Sometimes  this  belief  is 
carried  very  far.  For  example,  the  wearing  of  certain 
coloured  ties  will  indicate  definite  meanings.  This  form  of 
mental  disorder  has  been  called  Symbolising  Insanity,  but  it 
is  merely  a  symptom  commonly  met  with  in  chronic  delu- 
sional insanity.  There  is  a  type  of  paranoia  which  has  been 
termed  rehgious  paranoia.  The  patient  believes  that  he 
has  some  great  mission  to  perform  and  that  the  Deity  has 
especially  endowed  him  with  power  to  perform  it.  His 
conduct  is  often  very  unrehable.  These  patients  seldom 
have  hallucinations,  but  they  are  usually  mystic  and  see 
meaning  in  everything. 

Before  passing  on  to  the  physical  symptoms  of  paranoia, 
it  will  be  convenient  to  mention  here  a  condition  known  as 
folie  a  deux,  or  communicated  insanity.  This  form  of 
mental  disorder  is  found  in  other  varieties  of  insanity,  but 
is  most  frequently  met  with  in  association  with  chronic  delu- 
sional insanity  and  is  therefore  referred  to  here.  Contact 
insanity  is  exceedingly  rare,  and  is  a  negligible  quantity  in 
the  treatment  of  the  insane.  It  is  an  almost  universal  rule 
that  persons  who  become  insane  in  consequence  of  association 
with  the  insane  are  neurotic  or  of  very  unstable  inheritance. 
Insanity  of  this  kind  probably  never  occurs  in  institutions 
for  the  treatment  of  mental  disease,  but,  as  a  rule,  in  a  private 
house,    where    two    or   three   neurotic   individuals    are   living 


152  PSYCHOLOGICAL  MEDICmE 

together.  The  physicians  and  nurses  in  constant  attendance 
on  the  insane  do  not  develojD  mental  disease  more  frequently 
than  those  whose  work  is  the  care  of  patients  suffering  from 
physical  disease,  and  in  most  cases  there  is  a  definite  cause  for 
the  break-down.  By  the  term  folie  a  deux  is  meant  that  an 
insane  person  has  communicated  to  a  sane  person  living 
with  him  a  neurotic  disorder  similar  to  his  own.  Great  care 
must  be  taken  not  to  draw  a  mistaken  inference  from  the 
development  of  insanity  by  two  neurotic  persons  at  the  same 
time,  and  to  attribute  the  insanity  of  the  one  to  the  morbid 
effects  of  association  with  the  other. 

That  a  man  believes  the  statements  of  his  insane  relative 
to  be  true  does  not  constitute  insanity  ;  but  if  he  not  only 
believes  them,  but  acts  upon  the  belief  and  regulates  his  life 
and  conduct  accordingly,  then  he,  too,  must  be  adjudged  to 
be  of  unsound  mind.  Many  persons  will  readily  believe  the 
statements  of  others,  however  wildly  extravagant  they  may  be  ; 
but  they  will  not,  so  long  as  sanity  is  maintained,  compromise 
themselves  by  acting  upon  them.  These  considerations  may 
have  a  very  important  medico-legal  aspect.  Persons  may 
thus  be  able  to  bring  corroborative  evidence  in  support  of 
accusations  either  against  themselves  or  others.  Savage 
reports  that  in  a  police  district  in  London  he  was  told  by 
the  divisional  surgeon  that  a  whole  family  supported  the 
insane  statements  of  the  father,  the  members  of  this  family 
being  themselves  weak-minded  and  influenced  by  his  delusions. 
Delusions  of  persecution  are  the  most  common  delusions  that 
are  met  with  in  this  type  of  mental  disorder. 

Physical  Symptoms. — The  physical  health,  at  first,  does  not 
always  suffer  to  any  marked  degree  in  chronic  delusional 
conditions.  After  a  time,  owing  to  deficient  sleep,  the  patient 
may  show  signs  of  loss  in  weight  and  other  symptoms  of 
disordered  nutrition.  Some  patients,  who  believe  that  they 
are  tampered  with  at  night,  will  keep  themselves  awake ; 
others  have  disturbed  sleep  owing  to  sensory  disturbances, 
which  are  misinterpreted  into  electric  shocks.  A  patient  may 
starve  himself  rather  than  take  food  which  he  beheves  has 
been  dragged.  From  such  causes  the  health  may  suffer,  and 
the  various  systems  of  the  body  become  disordered.  On  the 
other    hand,    some    patients    lose    weight    rapidly   from    the 


CHRONIC  DELUSIONAL  INSANITY  153 

beginning  and  frequently  become  very  anaemic.  In  the  female 
the  catamenia  may  be  irregular,  both  in  quantity  and 
periodicity.  Sexual  malpractices  in  both  sexes  may  lead 
to  muscular  tremor  and  other  fatigue  symptoms.  In  some 
delusional  cases  the  health  is  excellent. 

Course. — The  disease  is  of  such  slow  development  that  it 
may  not  be  recognised  for  some  years.  It  rmis  a  chronic 
course,  but  from  time  to  time  there  may  be  outbursts  of 
excitement.  The  delusions  slowly  become  systematised  and 
organised,  and  after  many  years  they  generally  become  less 
intense.  The  progress  of  the  disease  may  stop  at  any  stage  ; 
some  persons  always  believe  themselves  to  be  persecuted, 
while  others  pass  from  persecution  to  exaltation.  Usually 
as  the  disease  advances  the  attention  becomes  more  and 
more  absorbed  in  the  new  ideas.  Chronic  delusional  insanity 
does  not  tend  rapidly  to  dementia,  and  even  when  it  occurs, 
the  mental  weakness  is  not  always  very  marked. 

Diagnosis. — The  diagnosis  in  the  early  stages  may  not  be 
easy.  It  is  often  very  difficult  to  distinguish  between  insanity 
and  eccentricity.  As  has  been  akeady  pointed  out,  the  dis- 
order sometimes  seems  to  develop  out  of  a  morbid  mental 
constitution,  and  it  is  then  very  difficult  to  draw  the  line 
of  demarcation  that  separates  sanity  from  insanity.  The 
characteristic  symptom  of  the  condition  is  the  growth  of 
delusions  which  slowly  become  systematised.  The  absence 
of  strong  emotional  states  also  helps  in  forming  a  right 
diagnosis.  Further,  the  memory  does  not  fail  to  any  marked 
exterrt  and  there  is  not  severe  mental  deterioration. 
At  times  it  may  be  difficult  to  distinguish  paranoia  from 
the  condition  known  as  dementia  paranoides  (dementia 
prsecox).  But  in  the  latter  the  delusions  are  more  quickly 
developed  and  lack  system,  and  they  are  usually  accompanied 
by  greater  emotional  disturbance ;  also  there  is  a  greater 
tendency  to  have  hallucinations,  and  the  patient  has 
the  mannerisms,  negativism,  etc.,  common  to  all  cases  of 
dementia  prsecox.  Further,  these  patients  tend  to  become 
weak-minded  and  to  forget  their  delusions  ;  whereas  with  the 
paranoiac  there  is  no  such  tendency,  and  the  delusions,  as 
time  passes,  become  more  systematised.  Delusional  insanity 
in  its  later  stages  may  be  confused  with  general  paralysis.     The 


154  PSYCHOLOGICAL  MEDICINE 

casual  observer  is  always  apt  to  diagnose  general  paralysis 
when  the  mental  aspect  is  one  of  extreme  exaltation.  The 
paranoiac  may  have  very  expansive  ideas,  and  an  accurate 
diagnosis  can  only  be  made  by  the  presence  or  absence  of 
physical  signs  of  organic  disease.  Great  reliance  must  be 
placed  on  the  history,  for  paranoia  is  a  slowly  progressive 
disease  in  which  the  delusions  become  more  and  more 
systematised  as  time  passes. 

Prognosis. — The  prognosis  is  decidedly  bad.  Patients  may 
improve  and  be  able  to  be  discharged  from  care,  but,  as  a  rule, 
there  is  an  early  relapse.  Most  paranoiacs  become  hopelessly 
insane  and  unfit  to  be  at  large.  This  disorder  does  not  tend 
to  shorten  hfe,  and  many  of  these  patients  live  to  old  age. 

Pathology  and  Morbid  Anatomy. — There  is  very  Httle  known 
as  to  the  pathology  of  this  condition,  but  probably  in  a 
certain  number  of  the  cases  there  is  some  disorder  of  general 
or  special  sensations.  As  before  observed,  altered  sensation 
leads  to  an  altered  idea  of  self.  In  other  cases  there  seems  to 
be  morbid  development  from  childhood.  The  hypersensitive- 
ness,  which  is  born  in  them,  brings  about  their  downfall.  They 
see  insults  where  none  w^ere  intended  and  view  the  world 
with  suspicion. 

Treatment. — There  is  but  Httle  special  treatment  for  this 
disorder.  Early  diagnosis  is  a  matter  of  great  importance,  for 
in  a  certain  number  of  cases  change  of  scene  and  occupation 
and  careful  supervision  wisely  exercised  may  arrest  or  greatly 
retard  the  development  of  delusions.  This  is  one  of  the  few 
forms  of  insanity  that  can  be  treated  in  their  early  stages  by 
travelHng,  but  if  the  delusions  are  at  all  marked,  foreign  travel 
is  contra-indicated.  Home  is  always  the  worst  place  for  the 
chronic  delusional  patient,  as  he  quickly  suspects  the  actions 
and  intentions  of  his  friends.  There  may  be  some  difficulty  in 
obtaining  certificates  of  mental  unsoundness  in  these  cases. 
The  visit  of  a  medical  man  serves  to  put  the  patient  on  his 
guard.  Often  several  visits  are  necessary  before  sufficient 
evidence  of  insanity  can  be  obtained.  The  conduct  is  usually 
at  first  more  erratic  than  the  conversation,  and  the  latter 
can  be  controlled  at  will.  The  dangers  of  homicide  or  suicide 
must  never  be  lost  sight  of,  insane  persons  of  this  class  being 
quite  the  most  dangerous  in  these  respects.    For  this  reason 


'^CHRONIC  DELUSIONAL  INSANITY  155 

early  discharge  from  an  asylum  on  apparent  recovery  is  not 
advised  ;  detention  during  several  weeks  of  convalescence  is 
more  prudent.  If  there  is  any  known  physical  basis  for  the 
mental  disorder,  this  should  be  treated  ;  but  in  the  absence  of 
this,  the  methods  adopted  must  be  on  the  lines  laid  down  in 
the  chapter  on  Treatment. 


156  PSYCHOLOGICAL  MEDICINE 


CHAPTEE  X 

DEMENTIA  PRECOX 

The  term  Dementia  Praecox  has  been  a  topic  for  discussion 
both  in  this  comitry  and  abroad  for  the  past  few  years.  It 
is  somewhat  doubtful  who  originally  introduced  the  term,  but 
it  is  Kraepelin  who  has  invested  it  with  special  interest.  He 
does  not  seem  to  claim  that  he  has  discovered  a  new  or  dis- 
tinct disease  ;  his  aim  appears  rather  to  be  directed  to  group- 
ing together  diseases  which  tend  to  early  dementia.  Followers 
of  Kraepelin,  however,  have  gone  farther,  and  have  endowed 
the  title  Dementia  Prsecox  with  greater  meaning.  There 
is  no  doubt  that  the  introduction  of  this  term  has  akeady 
done  much  good  in  enforcing  upon  physicians  the  duty  of 
diagnosis.  The  study  of  mental  disease  is  still  in  its  infancy, 
and  the  tendency  in  the  past  has  been  to  lay  too  much  stress 
on  individual  symptoms.  In  this  respect  the  investigation 
of  mental  disease  does  not  differ  from  the  early  study  of  disease 
in  general.  As  knowledge  progresses,  it  becomes  possible  to 
divide  disease  into  groups  and  by  experience  to  allocate  parti- 
cular disorders  to  particular  divisions  or  sub-divisions  of  disease. 

There  is  safety  in  generalisation,  which  is,  to  some  extent, 
excusable  in  the  early  days  of  knowledge.  An  instance  of 
this  cautious  attitude  is  to  be  found  in  the  use  of  the  term 
*  chronic '  by  many  authorities.  To  say  that  a  disease  is 
chronic,  when  it  has  lasted  for  a  long  time,  does  not  require 
great  enlightenment.  A  layman  can  ex  ■post  facto  say  that  a 
disease  is  chronic  in  the  sense  that  it  has  lasted  over  a  period 
of  time.  The  physician  should  be  able  to  detect  chronicity, 
in  the  sense  that  the  disease  is  destined  to  extend  over  a  long 
time,  at  its  first  onset.  Some  diseases  are  chronic  from  their 
beginning,  and  educated  discernment  makes  a  diagnosis  of 
chronicity  possible.     It  seems   that  Kraepelin,  in  using  such 


DEMENTIA  PRECOX  157 

terms  as  dementia  prsecox,  invites  the  physician  to  make  a 
diagnosis  and  not  to  postpone  prophecy  mitil  after  the  event. 
Many  persons  consider  that  the  present  use  of  the  term 
dementia  prsecox  is  too  wide,  as  including  in  its  Hmits  diseases 
which  would  be  better  classed  under  other  heads.  It  has, 
however,  this  advantage,  that  it  is  a  step  towards  making 
our  diagnosis  more  correct,  or  even  towards  inducing  diagnosis 
at  all ;  for  to  state  that  a  person  is  suffering  from  dementia 
praecox  connotes  from  the  first  an  expression  of  opinion  that  he 
is  suffering  from  a  chronic  malady.  The  critic  may  dispute  the 
conclusion  and  object  that  a  sufferer  from  this  disease  may 
recover.  To  some  extent  his  criticism  is  just,  as  in  some  cases 
there  is  such  apparent  recovery  as  permits  of  discharge  from 
care.  The  word  '  recovery  '  must,  however,  be  used  in  con- 
junction with  the  word  '  apparent.'  There  is  no  recovery  in 
an  unqualified  sense.  Sooner  or  later  there  will  be  a  relapse, 
and  the  end  will  be  dementia.  No  physician  would  say  that 
general  paralysis  is  a  cm-able  disease,  and  yet  the  general 
paralytic  frequently  leaves  an  asylum  in  a  state  of  remission 
so  complete  that  his  friends  consider  he  has  quite  recovered. 

Dementia  praecox  is  a  disorder  in  which  there  is  a  special 
grouping  of  symptoms  and  in  which  the  illness  runs  a  definite 
course. 

etiology. — Defective  heredity  is  found  in  a  very  large 
proportion  of  these  cases  ;  and  this  is  to  be  expected,  for 
dementia  prsecox  is  an  insanity  occurring  in  early  life.  Broadly 
speaking,  persons  suffering  from  mental  disorder  at  puberty 
or  adolescence  usually  have  a  neuropathic  inheritance.  It 
may  occur  in  either  sex  and  in  any  rank  of  life.  Masturba- 
tion has  been  held  to  be  an  important  factor  in  the  production 
of  the  disease,  but  this  is  probably  not  the  case  ;  onanism 
is  rather  a  symptom  than  a  cause.  Some  of  these  patients 
may  never  have  exhibited  any  real  intellectual  brightness, 
but  may  have  always  been  dull  and  reserved  ;  others  may 
have  been  exceptionally  brilliant. 

Vaxieties. — There  are  three  main  groups  of  cases  usually 
described  under  the  head  of  dementia  praecox :  (a)  Hehe- 
'phrenia ;  (&)  Catatonia ;  (c)  Dementia  Paranoides.  Though 
these  are  the  common  types  described  by  Kraepelin,  from  time 
to  time  mixed  varieties  may  be  found.    For  example,  a  patient 


158  PSYCHOLOGICAL  MEDICINE 

may  exhibit  the  hebephrenic  form  and  later  develop  the 
symptoms  of  dementia  paranoides. 

Mental  Sjmiptoms. — There  are  certain  mental  character- 
istics to  be  fomad  in  all  types  of  this  disorder.  Consciousness 
is  usually  clear,  and  perception  is  good.  The  patient,  as  a  rule, 
reaHses  his  relationship  to  others,  and  orientation  is  fairly 
correct.  In  the  paranoid  form  delusions  may  lead  to  mis- 
interpretation and  errors  in  deciding  the  identity  of  those 
persons  with  whom  the  patient  is  thrown  into  contact.  General 
apathy  and  loss  of  interest  are  early  symptoms.  The  patient 
loses  affection  for  his  relatives  ;  he  is  indifferent  to  pleasure 
and  pain  alike — ^in  short,  there  is  a  general  loss  of  emotional 
reaction.  It  is  no  doubt  for  this  reason  that  the  patient  with 
dementia  prsecox  so  readily  settles  down  to  an  asylum  life 
without  evincing  the  sHghtest  resentment. 

Although  there  is  a  loss  of  emotional  reaction,  there  is  a 
symptom  which  is  very  characteristic  of  the  condition,  and 
that  is,  sudden  outbm'sts  of  laughter  with  no  apparent  cause, 
which  symptom  may  appear  quite  early  in  the  disorder.  The 
sesthetic  sentiments  are  lost,  and  the  patient  is  careless  of  his 
personal  appearance.  His  general  conduct  is  that  of  indiffer- 
ence, and  he  seldom  exhibits  any  voluntary  activity.  He  sits 
about  mioccupied,  and  everything  seems  too  much  trouble ; 
often  he  wiU  neither  wash  nor  dress  himself,  further,  there 
are  several  disorders  of  action  which  are  almost  characteristic 
of  the  condition.  There  is  an  automatic  obedience  (Echopraxia), 
in  which  the  patient  imitates  any  action  performed  in  front 
of  him,  such  as  raising  the  arm,  clenching  the  fist,  etc.  This 
is  similar  to  the  tendency  of  the  patient  to  repeat  questions 
asked  or  remarks  made  to  him  (Echolalia).  Another  disorder 
of  action  is  that  known  as  Flexibilitas  Cerea.  In  this  con- 
dition the  limbs  can  be  easily  moulded  into  various  positions, 
where  they  will  often  remain  for  a  considerable  time.  Negativ- 
ism is  also  a  very  constant  symptom  of  all  types  of  dementia 
prsecox.  It  is  a  state  in  which  any  suggestion  made  by  another 
immediately  raises  in  the  patient  a  counter-suggestion,  and  for 
this  reason  he  frequently  opposes  or  resists  everything  that 
is  done  for  him.  Maimerisms  and  tricks  of  all  kinds  can 
commonly  be  observed,  such  as  touching  objects,  contortions, 
grimacing,  etc.     The  attention  is  impaired  early  ;  the  absence 


DEMENTIA  PRECOX  .159 

of  all  concentration  in  the  way  of  active  attention  is  often 
a  very  prominent  symptom.  The  memory  may  for  a  long 
time  remain  unimpaii'ed,  though  as  the  disease  advances  it 
becomes  more  uncertain.  There  seems  to  be  decided  failure 
of  the  power  to  associate  ideas.  He  plays  with  syllables  and 
words,  and  in  the  letters  which  he  writes  the  subject-matter 
is  disjointed  and  the  expressions  he  uses  are  often  extravagant 
and  mal  a  'propos. 

.  Delusions  of  persecution,  exaltation,  or,  in  fact,  almost  of 
every  type,  usually  appear  during  the  early  stages  of  the 
disease,  but  as  time  passes  they  become  less  marked  and  may 
even  be  forgotten,  and  the  patient  finally  ceases  to  base  his 
conduct  and  life  upon  them,  as  he  was  formerly  wont  to  do. 
Hallucinations,  more  especially  auditory  and  visual,  are  com- 
monly present,  but,  like  delusions,  they  disappear  or  become 
less  vivid  as  the  disorder  progresses. 

(a)  HebepJirenic  Form. — The  initial  stage  of  this  form  of 
dementia  prsecox  is  frequently  overlooked.  It  occurs  usually 
in  the  first  twenty-five  years  of  life.  The  changes  in  the 
patient's  character  and  general  temperament  are  so  slow 
and  insidious  that  at  first  they  are  disregarded  or  explained 
away.  The  active  child  may  become  indifferent  and  way- 
ward ;  the  frank  and  ingenuous,  sullen  and  reserved.  In 
other  words,  aU  that  went  to  make  the  character  is  lost,  and 
in  its  place  there  are  idleness  and  irritability.  As  weeks  and 
months  pass  the  changes  become  more  marked,  indolence 
develops  into  profound  idleness,  and  the  patient  will  lie  in  bed 
all  day,  if  not  disturbed,  and  will  make  no  attempt  to  work. 
Out  of  doors,  patients  of  this  type  are  apt  to  wander  on  until 
they  lose  themselves,  and  they  are  careless  of  all  traffic  and 
heedless  of  any  impending  dangers.  Their  conversation  is  in 
jerky  sentences  and  only  consists  of  replies  to  questions  put 
to  them.  Attention  steadily  fails,  and  concentrated  thought 
is  impossible.  These  patients  will  frequently  repeat  the 
question  before  answering  it  (Echolalia).  Sexual  mal- 
practices may  be  also  an  important  and  trying  symptom  in 
the  earlier  stages  of  the  disease.  Obscene  language  and  the 
writing  of  indecent  letters  are  common  features  of  the 
disorder.  Females  are  usually  worse  during  the  catamenial 
periods. 


160  PSYCHOLOGICAL  MEDICINE 

The  mental  attitude  of  the  patient  may  be  one  of  either 
depression  or  excitement,  but,  as  a  rule,  the  initial  phases  are 
marked  by  melancholia  and  ideas  of  un worthiness.  Delusions 
of  any  kind  may  develop,  and  frequently  they  are  based  upon 
religious  belief.  If  exaltation  and  excitement  supervene,  the 
type  of  the  delusions  changes.  Sexual  ideas  may  play  a 
prominent  part  and  lead  to  the  making  of  false  charges. 
Hallucinations  may  appear  ;  the  patient  may  see  visions  or 
hear  voices  ;  he  may  taste  poison  in  his  food,  or  smell  foul 
gases.  The  responsibility  for  instigating  these  annoyances  is 
fixed  upon  some  person  or  persons,  and  efforts  at  retaliation 
may  be  made.  Frequently  suicide  will  be  attempted,  the 
reasons  attributed  for  the  act  being,  as  a  rule,  very  childish. 
The  conduct  generally  is  foolish  and  no  effort  towards 
occupation  is  made.  Carelessness  and  untidiness  in  dress  are 
characteristic  symptoms.  Eccentricities  and  mannerisms  in 
speech  and  action  may  be  prominent,  such  as  have  already  been 
described.  These  depressive  hebephreniacs  may  become  quite 
cheerful  and  laugh  for  a  few  minutes  and  then  again  relapse 
into  melancholy. 

(b)  Catatonic  Form. — This  type  of  dementia  praecox  may 
develop  in  an  insidious  manner.  There  may  be  several  weeks 
of  a  general  feeling  of  malaise.  The  patient  has  difficulty  in 
concentrating  his  attention  ;  he  becomes  sleepless  and  mildly 
depressed.  As  time  passes,  the  symptoms  become  more  exag- 
gerated, and  his  fears  take  a  more  active  form.  Delusions 
of  unworthiness  and  impending  harm  disturb  him  by  night 
and  by  day.  Hallucinations  of  sight  and  of  hearing,  and 
less  frequently  of  taste  and  smell,  begin  to  annoy  him.  He 
becomes  more  and  more  irritable  and  depressed.  He  loses 
all  interest  in  his  surroundings,  and  his  whole  thoughts  are 
centred  round  himself  and  his  misfortunes.  Mutism  may 
be  a  prominent  symptom,  but  it  is  broken  from  time  to  time 
by  the  monotonous  repeating  of  words  and  phrases  (verbi- 
geration). The  patient  may  steadily  pass  into  a  condition  of 
catatonic  stupor,  fully  described  elsewhere.  On  the  other 
hand,  in  the  place  of  stupor  there  may  be  catatonic  excitement. 
The  characteristics  of  the  catatonic  state  are  negativism 
(resistance  to  passive  movements),  fixed  attitudes,  grimacing, 
stereotyped  movements,  and  verbigeration.     The   rigidity  is 


DEMENTIA  PRECOX  161 

uniformly  distributed,  and  involves  the  trunk  and  limbs  and, 
in  some  cases,  the  face. 

(c)  Paranoid  Form. — This  variety  is  especially  character- 
ised by  the  presence  of  delusions  and  hallucinations  and  by  a 
tendency  to  progressive  mental  deterioration.  Delusions  are 
commonly  present  in  the  other  types  of  dementia  praecox,  but 
they  tend  to  disappear  as  the  mental  enfeeblement  supervenes. 
It  occurs  in  older  persons  than  is  the  case  with  the  hebephrenic 
variety.  These  paranoid  forms  have  been  divided  into  two 
main  groups  according  to  the  coherency  of  the  delusions,  the 
presence  of  emotional  excitement,  the  rapidity  with  which 
dementia  comes  on,  and  the  persistence  of  the  delusions  ;  but 
this  seems  too  great  a  refinement  and  in  the  present  description 
all  cases  will  be  grouped  in  one  class.  Much  that  has  been 
written  of  the  prodromal  stages  of  paranoia  again  apphes  here, 
and  this  period  may  be  long  or  short  in  duration.  Commonly 
there  is  a  period  of  insomnia  and  general  failure  of  attention. 
In  the  course  of  time  strange  delusions  are  expressed.  The 
patient  fears  that  some  conspiracy  is  being  formed  against  him. 
He  imagines  that  he  is  jeered  at  in  the  streets  and  that  everyone 
makes  fun  of  him  ;  in  short,  that  he  is  constantly  being  annoyed 
and  persecuted  in  numerous  little  ways.  The  sufferer  may  give 
up  his  occupation  through  some  quarrel  with  his  employer 
or  colleagues.  Delusions  of  grandeur  may  develop,  and  exist 
side  by  side  with  the  ideas  of  persecution.  The  patient  may  be 
exalted  as  to  his  rank  or  financial  position  ;  he  may  beHeve  that 
his  mission  is  to  reclaim  the  world.  Some  of  these  patients 
write  countless  letters  and  fill  quires  of  paper  with  their  de- 
lusions. They  are  proud  of  their  position  and  are  constantly 
talking  of  what  they  have  to  do.  In  this  they  differ  from 
patients  suffering  from  systematised  delusional  insanity,  for 
the  latter  are  usually  suspicious  and  reticent.  The  patient 
with  dementia  praecox  reaHses,  at  any  rate  for  some  considerable 
time,  that  to  the  world  at  large  his  ideas  do  seem  extravagant, 
but  he  puts  it  down  to  ignorance  on  the  part  of  the  pubhc. 
He  is  pleased  to  discuss  his  beliefs  and  makes  strenuous  efforts 
to  prove  them.  Hallucinations,  almost  always  of  hearing,  are 
often  prominent.  Outbursts  of  impulsive  excitement  of  very 
short  duration  may  occur.  The  conduct  is  usually  in  keeping 
with  the  delusions  ;  at  first  these  patients  are  frequently  well- 

11 


1 62  PSYCHOLOGICAL  MEDICINE 

behaved,  and  only  as  consciousness  becomes  more  clouded 
does  their  behaviour  begin  to  be  erratic. 

Physical  Symptoms. — The  physical  health  suffers  to  a 
greater  extent  in  the  hebephrenic  and  catatonic  forms  than  it 
does  in  the  paranoid  varieties.  In  some  cases  the  bodily 
disturbances  are  very  sHght  indeed,  and,  except  for  a  loss 
of  body  weight  and  some  constipation,  no  symptoms  are  to  be 
-remarked.  In  other  cases  the  functional  derangements  may 
be  very  marked  and  include  disturbances  of  all  the  systems 
of  the  body.  After  some  months  or  years  the  functions  may 
re-establish  themselves,  and  from  this  time  onwards  there  is 
a  tendency  for  the  patient  to  become  unduly  stout.  The  pulse 
tension  is  very  low  and  the  extremities  are  cold  and  cyanosed. 
The  handshake  is  very  characteristic  when  the  disease  is  fully 
developed,  the  hand  is  held  out  stiffly  and  straight,  and  the 
thumb  is  not  used  to  grasp  with. 

Course. — The  course  of  the  disease  is  progressive,  in  that  the 
patient  slowly  but  steadily  becomes  more  and  more  weak- 
minded.  In  a  certain  percentage  of  cases  the  progress  of  the 
malady  seems  to  undergo  arrest,  and  the  patient  may  remain 
for  some  years  in  a  partially  demented  condition.  In  all  the 
varieties  of  dementia  prsecox  consciousness  becomes  more 
clouded  with  the  passage  of  time.  Memory  does  not  always 
suffer  to  a  very  marked  degree,  but  as  the  power  of  forming 
associations  fails  and  the  faculty  of  attention  disappears,  the 
memory,  of  necessity,  becomes  more  defective.  Nevertheless, 
the  more  remote  memory  may  suffer  but  little.  Environment 
is  of  small  consequence  to  these  patients  in  the  later  stages 
of  the  disease,  as  they  usually  settle  down  anywhere  with 
surprising  contentment.  All  power  of  comparison  is  lost,  and 
their  fate  is  accepted  without  complaint.  Their  only  want  is 
a  plentiful  supply  of  food. 

(a)  Hebefhrenic  Form. — The  rapidity  with  which  dementia 
supervenes  varies  in  these  cases  from  about  eight  months 
to  several  years.  The  excited  hebephreniac  degenerates  more 
rapidly  than  the  depressive  type,  and  dementia  may  supervene 
within  a  very  few  months.  In  a  small  proportion  the  weak- 
mindedness  never  becomes  very  profound,  and  in  some  instances 
it  may  be  possible  for  the  patient  to  return  home,  provided  his 
financial  position  is  such  that  he  can  be  well  looked  after. 


DEMENTIA  PRECOX  163 

There  is,  however,  always  a  risk  that  he  may  fall  into  the 
hands  of  some  unscrupulous  person  who  will  take  advantage 
of  his  childishness.  Throughout  the  course  of  the  disease  the 
patient  is  liable  to  periods  of  excitement  and  great  impulsive- 
ness, during  which  acts  of  violence,  against  himself  or  others, 
may  be  perpetrated.  Hallucinations  usually  become  less 
vivid  or  disappear,  and  the  early  delusions  may  be  lost,  or, 
at  any  rate,  are  no  longer  the  active  principles  upon  which 
the  patient  bases  his  conduct.  A  certain  number  of  cases 
develop  some  exaltation,  but  rarely  of  an  extreme  kind.  The 
majority  become  useless  members  of  society  and  merely  live 
a  vegetative  existence.  Some  can  be  trained  to  do  simple  work, 
such  as  carrying  and  cleaning,  and  in  this  way  may  become 
valuable  additions  to  an  asylum  community. 

(b)  Catatonic  Form. — In  this  variety  the  progress  towards 
dementia  is  a  fairly  rapid  one,  but  it  may  be  broken  from 
time  to  time  by  short  remissions  of  apparent  health.  The 
symptoms  during  the  earlier  stages  alternate  between  stupor 
and  excitement.  The  stuporose  patient  will  suddenly  become 
wildly  excited  and  extremely  restless.  He  may  throw  himself 
about  and  be  generally  destructive.  His  habits  become 
dirty.  His  speech  is  incoherent,  with  a  great  tendency  to  verbi- 
geration ;  his  movements  are  stereotyped  and  stilted.  The 
excitement  will  disappear  almost  as  suddenly  as  it  developed, 
and  again  the  patient  becomes  silent  and  stuporose.  As  in 
the  hebephrenic  variety,  the  dementia  may  vary  in  severity. 

(c)  Paranoid  Form. — This  type  runs  a  very  slow  but  pro- 
gressive course.  The  delusions,  as  a  rule,  gradually  change 
from  being  persecutory  in  character  to  those  of  general  exalta- 
tion and  grandeur,  the  latter  in  turn  becoming  less  marked 
as  the  mental  faculties  fail.  These  patients  are  usually  untidy 
and  occupy  themselves  less  and  less.  When  the  original  de- 
lusions are  referred  to,  they  deny  any  present  existence  of 
the  beliefs,  or  state  that  some  one  else  has  usurped  their 
authority.  They  never  show  any  hostility  when  the  dementia 
is  to  any  extent  developed,  and  they  remain  placidly  indolent 
throughout  the  rest  of  their  life. 

Diagnosis. — The  disease  begins  during  early  life,  from  puberty 
to  about  twenty-five  years  of  age,  but  the  paranoid  form  may 
develop  somewhat  later.      The  period   of  incubation   is  fre- 


164  PSYCHOLOGICAL  MEDICINE 

quently  a  long  one,  and  this  early  stage  may  be  overlooked. 
It  is  distinguished  from  imbecility  by  the  history,  for  in  the 
latter  the  patient  will  have  been  mentally  weak  for  several 
years  ;  while  in  the  former  the  child  develops  more  or  less 
norrnaUy  up  to  puberty  or  later,  when  signs  of  intellectual 
deterioration  begin  to  declare  themselves.  When  the  mental 
failure  is  steadily  progressive  and  forms  the  chief  feature  of 
the  disease,  the  diagnosis  is  comparatively  easy.  When 
excitement  or  depression  is  the  prominent  symptom,  it  is 
necessary  to  distinguish  it  from  the  maniacal- depressive  form 
of  insanity.  The  early  development  of  hallucinations  point 
to  dementia  preecox.  Verbigeration  and  stereotyped  move- 
ments and  rigidity  all  faA'om*  dementia  praocox.  The  physician 
must  bear  in  mind  the  possibility  of  juvenile  general  paralysis, 
but  in  the  latter  disease  there  is  usually  not  only  a  history  of 
syphilis  in  one  or  both  parents,  but  congenital  syphilitic 
phenomena  may  be  observed  in  the  patient.  Further,  the 
presence  or  absence  of  physical  signs  of  general  paralysis 
will  assist  in  the  diagnosis. 

The  differential  diagnosis  between  the  paranoid  form  of 
dementia  prsecox  and  systematised  delusional  insanity  or 
paranoia  may  appear  somewhat  difficult.  Nevertheless,  the 
diseases  are,  in  reaUty,  very  different  when  carefully  studied. 
Systematised  delusional  insanity  begins  in  a  different  way ; 
there  is  no  marked  change  in  the  patient's  emotional  state, 
and  his  manner  is  that  of  suspicion  ;  his  delusions  slowly 
become  more  organised  and  elaborated.  The  true  paranoiac 
never  becomes  profoundly  weak-minded — in  fact,  the  chief 
reason  that  his  intellect  fails  at  all  is  that,  owing  to  his 
delusions,  he  becomes  mono-ideational,  as  his  thoughts  are 
concentrated  in  one  groove.  The  picture  of  the  patient  with 
dementia  prsecox  is  very  different,  for  his  delusions  show  no 
great  cohesion.  The  emotions  are  commonly  disturbed  by 
excitement  and  depression.  There  is  no  difficulty  in  persuading 
him  to  talk,  and  he  will  readily  expound  all  his  beliefs. 

Prognosis. — The  prognosis  is  decidedly  bad,  the  only  question 
being  as  to  the  extent  to  which  the  dementia  will  develop. 
In  some  cases  there  will  be  a  remission,  but  in  time  this  is 
followed  by  another  attack,  during  which  the  disease  will 
further  progress. 


PLATE   I 

1. — Outer  surface  of  the  right  hemisphere  of  the  brain  of  a  female  aged  56 
years.  Previous  attack  five  years  before  admission  into  the  asylum.  Died 
fifteen  days  after  admission.  No  dementia.  Weight  after  stripping,  495 
grammes.  Except  for  a  small  patch  of  old-standing  sclerosis  in  the  middle  of 
the  ascending  parietal  gyrus,  there  is  little  or  nothing  to  indicate  that  the 
brain  is  not  perfectly  normal. 


2. — Outer  sm'face  of  the  left  hemisphere  of  the  brain  of  a  female  aged  3(> 
years.  >Symptoms  for  nine  years.  A  gross  lesion  of  the  right  hemisphere, 
with  resulting  epileptiform  convulsions,  was  present.  The  patient  was  an 
unstable  case  with  little  or  no  dementia.  Weight  after  stripping,  488  grammes. 
Except  for  a  little  rounding  off  of  the  convolutions  *of  the  frontal  lobe,  the 
parietal  lobules,  and  the  first  temporal  gyrus,  the  hemisphere  would  readily 
pass  for  normal. 


H. — -Outer  surface  of  the  right  hemisphere  of  the  brain  of  a  female  aged  59 
y(!ars.  Symptoms  for  about  eleven  years.  At  (irst  the  patient  showed  a 
certain  amount  of  mental  confusion,  and  at  the  time  of  her  death  she  was 
in  a  condition  of  chronic-  mania  with  dementia.  Weight  after  stripping,  515 
diamines.  This  heniisplici'c  differs  from  those  in  the  two  previous  figures  in 
Nhowing  (Ictinitc  wasting,  with  marked  rounding  off  of  the  convolutions  in  the 
frontal  lobe,  the  parietal  lobules,  and  the  liist  temporal  gyrus.  Near  the  mid- 
linr^  (not  seen  in  the  figure)  the  pre-frontal  region  is  more  wasted  than  the 
re.niain<ler.  hut  elsewhere  no  difEerentiation  of  the  wasting  is  visible. 


PLATE  I. 


1. 


..'>y'<  f- — ^'' 


PLATE   II. 

l._Outer  surfare  of  the  left  hemisphere  of  the  brain  of  a  female  aged  5:i. 
Previous  attaek  at  the  age  of  48,  witli  probably  no  real  recovery.  A  marked 
case  of  dementia  ;  weight  after  stripping,  445  grammes.  The  hemisphere 
shows  wasting,  which  is  extreme  in  the  pre-frontal  region,  considerable  in 
the  senson-motor  area  and  the  first  temporal  gjTus,  fairly  marked  in  the 
parietal  lobules,  and  less  marked  elsewhere. 


2, Outer  surface  of  the  right  hemisphere  of  the  brain  of  a  female  aged  .53. 

Seven  years  in  an  asylum.  Died  in  a  condition  of  gross  dementia.  Weight 
after  stripping,  355  grammes.  The  hemisphere  shows  wasting,  which  is 
very  extreme  in  the  pre-frontal  region,  extreme  in  the  posterior  thirds  of  the 
first  and  .second  frontal  convolutions  and  Broca's  gjTus,  marked  in  the  ascend- 
ing frontal  gyrus,  almost  as  marked  in  the  first  temporal  gyrus  and  the 
jsuperior  and  inferior  parietal  lobules,  and  moderate  elsewhere. 

Above  figures  together  with  those  of  Plate  1.  are  reproduced  from  Dr.  .J.  S. 
Bolton  s  paper  on  '  The  Histological  Basis  of  Amentia  and  Dementia,'  Archms 
of  Neurology,  vol.  ii. 


3. — ^Section  of  eerel)ral  foitcx  stained  Ijy  Kultschitzky-Woiters  method. 
Showing  foni  of  vascularity  and  chrome  depo.-^it.  The  mcduUated  fibres  only 
moderately  diseased.     Compare  with  normal  ineduUatcd  fibres,  Plate  XXV. 

Photomicrograph  originally  published  l)y  Dr.  E.  (Joodall  in  jy?-rt?/),  vol.  xxiii., 
to  illu.strate  paper  on  '  Condition  of  Mediillatcd  Fil)i-cs  in  Insanity.' 


PLATE  n. 

^ 

^. 

^^ 

DEMENTIA  PRECOX  165 

Treatment. — The  important  point  is  to  make  an  early 
diagnosis,  as  in  many  cases  it  is  possible  to  delay  the  progress 
of  the  disease  by  careful  treatment.  Eemoval  from  home  is 
usually  advisable.  Correct  bad  habits,  and  make  the  patient 
lead  a  very  regular  life.  Some  patients,  of  the  simple  hebe- 
phrenic variety,  may  remain  at  home  for  several  years  with 
absolute  safety,  provided  that  they  are  in  a  position  to  have 
some  one  to  look  after  them.  The  treatment  is  largely  that  of 
dealing  with  symptoms  as  they  arise  and  improving  the  general 
physical  health  of  the  patient.  In  some  cases  two  and  a  half 
grain  tablet  of  prostate  gland  once  a  day  is  very  helpful. 


166  PSYCHOLOGICAL  MEDICINE 


CHAPTEE  XI 

•      SECONDARY  DEMENTIA  AND   ORGANIC  DEMENTIA 

Secondaey  Dementia 

The  term  Dementia  is  used  to  indicate  a  state  of  mental 
enfeeblement,  the  result  of  disease  or  decay  of  the  nervous 
elements  of  the  brain.  It  is  a  state  produced  by  dissolution 
and  always  denotes  a  former  state  of  higher  intelligence. 
Idiocy  and  imbecility  are  conditions  of  amentia  due  to  failure 
of  evolution,  but  in  dementia  there  has  been  some  amount  of 
mental  development  which  has  become  degraded.  Dementia 
may  be  regarded  as  the  final  mental  state  of  all  men,  provided 
they  live  long  enough.  SeniUty  implies  a  diminished  capacity 
for  thought  and  general  slowing  of  aU  the  intellectual  faculties. 
In  some  men  the  physical  powers  decay  first,  in  others  the 
mental.  Now,  that  which  is  the  natural  concomitant  of  old 
age  may  be  produced  by  disease.  Some  authorities  use  the 
term  Dementia  merely  to  denote  a  mental  state,  no  matter 
whether  it  be  temporary  or  permanent.  This  general  and 
wide  use  of  the  word  makes  it  very  confusing  for  the  student 
and  in  many  ways  reduces  its  clinical  value.  For  example, 
acute  primary  dementia  is  a  synonym  for  anergic  stupor, 
which  is  a  recoverable  condition.  The  writer  prefers  to  reserve 
Dementia  to  designate  those  mental  disorders  in  which  there 
is  permanent  weak-mindedness.  The  word  '  dement '  is  very 
generally  used  in  asylums  to  denote  patients  whose  charac- 
teristic feature  is  weak-mindedness,  irrespective  of  the  original 
mental  disorder,  of  wliich  it  is  the  final  stage.  So  many  forms 
of  insanity  tend  to  dementia  that  it  is  more  scientific  to  look 
upon  this  state  as  the  last  mental  phase  of  these  different 
disorders,  and  clearly  it  is  wrong  to  describe  it  as  a  distinct 
malady. 


SECONDARY  DEMENTIA  167 

But  there  is  another  aspect  from  which  to  view  this  subject, 
for  although  it  is  true  that  dementia  is  merely  the  terminal 
stage  in  many  types  of  insanity,  it  is  an  important  stage,  in 
that  it  lasts  throughout  the  remaining  years  of  the  patient's 
life.  On  these  grounds  this  condition  calls  for  special  descrip- 
tion ;  and  the  reader,  understanding  that  no  new  malady 
is  being  described,  will  recognise  the  advantage  of  devoting  a 
few  pages  to  a  brief  record  of  the  special  symptoms  connected 
with  this  state.  In  former  chapters  the  student  has  been 
taught  to  look  upon  mania  and  melancholia  as  merely  groups 
of  symptoms  :  the  same  teaching  will  hold  good  here.  In 
order  to  emphasise  more  clearly  that  this  state  has  been  preceded 
by  some  other  type  of  mental  disorder,  the  prefix  '  secondary  ' 
is  usually  employed.  Thus  Secondary  Dementia  is  a  state 
of  mental  enfeeblement  which  may  occur  as  a  late  stage  in 
many  forms  of  insanity  and  is  marked  by  definite  symptoms 
below  described.  The  characteristic  features  of  the  original 
disorder  may  persist  and  in  this  way  colour  the  dementia. 
The  degree  of  weak-mindedness  may  vary  greatly,  from  a 
state  of  general  inattention  and  loss  of  power  of  concentrated 
thought  to  a  condition  of  profound  degradation. 

etiology. — Secondary  dementia  may  supervene  upon  many 
forms  of  insanity,  but  it  is  more  common  to  find  it  in  its 
advanced  type  as  the  final  stage  of  those  mental  disorders 
which  developed  during  early  adult  hfe.  A  nem'opathic  in- 
heritance is  usually  traceable.  Epilepsy  and  alcoholism  are 
especially  prone  to  produce  it. 

Mental  Symptoms. — The  mental  symptoms  vary  according 
to  the  degree  of  weak-mindedness.  Control  is  lessened,  and 
impulsive  actions  are  frequent.  Generally,  patients  of  this 
type  are  irritable  and  impatient  and  will  quickly  fly  into 
a  passion,  but  can  with  tact  be  as  rapidly  coaxed  into  good 
humour  again.  The  conduct  is  defective,  and  the  man  is  no 
longer  capable  of  adapting  himself  to  ever-changing  circum- 
stances. The  demented  person  may  fall  into  the  ways  of  an 
institution,  where  life  is  regular,  and  in  this  narrow  groove 
he  may  even  become  a  useful  member  of  the  asylum  com- 
munity. Such  a  patient  may  be  capable  of  doing  good 
manual  work  when  once  he  has  been  taught  it.  He  works  in  an 
automatic  manner  and  never  asks  for  a  holiday,  but  toils  on 


168  .       PSYCHOLOGICAL  MEDICINE 

more  like  a  macliine  than  a  human  being.  In  the  more 
advanced  forms  of  dementia  the  patient  is  totally  incapable 
of  work  ;  if  he  emi)lovs  himself  at  all,  it  is  rather  with  some 
destructive  than  constructive  occupation. 

The  feelings  and  emotions  are  always  affected,  and  the 
altruistic  sense  is,  to  a  great  extent,  lost.  A  demented  person 
is  indifferent  to  the  welfare  or  happiness  of  his  relatives  and 
will  hear  of  the  death  of  a  near  connection  without  evincing 
the  slightest  sign  of  regret.  Some  dements  are  liable  to  out- 
bursts of  maniacal  excitement.  The  sesthetic  sentiment  is  to 
a  great  extent  lost  or  strangely  perverted.  They  are  frequently 
untidy  and  difficult  to  keep  clean.  Some  of  these  patients  will 
decorate  themselves  with  ribbon  and  colom'ed  garlands  until 
their  appearance  is  grotesque.  Those  who  belong  to  the  lower 
planes  of  mental  weakness  are  usually  hopelessly  degraded  in 
their  actions  and  conversation.  They  will  eat  filth  from  the 
waste-bowl  and  conduct  themselves  in  an  utterly  degenerate 
manner.  They  seem  more  angesthetic  to  pain  than  the  normal 
person  and  seldom  com^Dlain.  The  memory  is  always  affected, 
to  a  greater  or  less  extent.  The  capacity  of  storing  fresh 
impressions  is  partially  or  totally  lost.  Some  dements  may 
exhibit  an  extraordinary  power  of  hypermnesia  in  a  certain 
direction,  such  as  dates,  but  it  is  always  accompanied  by  a 
corresponding  failm'e  in  the  general  faculty  of  recall. 

The  dement  is  usually  quite  unfit  to  administer  his  affairs,^ 
for  he  may  readily  become  the  dupe  of  any  unprincipled 
person  ;  still,  in  the  less  severe  forms  of  dementia  he  may  be 
capable  of  making  a  reasonable  will.  It  is  unnecessary  here 
to  discuss  this  question,  fm-ther  than  to  state  that  whenever  a 
physician  is  called  into  inquke  into  the  testamentary  capacity 
of  a  person  suffering  from  dementia,  he  should  conduct  his 
investigation  with  great  care  and  circumspection,  as  a  'priori 
the  patient  is  not  of  a  disposing  mind.  Suicidal  attempts 
are  decidedly  rare,  but  impulsive  violence  of  a  homicidal 
nature  is  more  common.  The  dement  is  usually  incapable  of 
devising  an  elaborate  scheme  of  violence  against  anyone,  and 
whatever  he  does  is  done  on  the  impulse  of  the  moment. 
Hallucinations  may  have  persisted  tln-oughout  the  iUness 
and  remain  during  the  final  phase  of  dementia  ;  but,  as  a 
general  rule,  they  are  less   heeded   and  fail  to  influence  the 


SECONDARY  DEMENTIA  169 

conduct  in  the  same  way  as  during  the  earlier  stages  of  the 
disease.  Other  mental  symptoms  may  be  present,  but  they  are 
more  closely  connected  with  the  original  mental  disorder  of 
■which  dementia  is  the  termmation. 

Physical  Symptoms. — In  many  cases  the  general  health 
improves  when  the  patient  becomes  weak-minded.  During 
the  early  stages  of  illness  nutrition  may  have  been  bad,  and 
symptoms  such  as  anorexia  and  insomnia  may  have  fm'ther 
undermined  the  strength  ;  but  as  mental  enfeeblement  appears, 
the  appetite  usually  improves,  and  there  is  greater  inclination 
to  sleep.  As  time  passes,  the  body  weight  increases  and  the 
various  functions  are  normally  performed.  There  are  many 
exceptions  to  this  rule,  more  especially  in  those  cases  where  the 
excitement  and  restlessness  persist.  Some  dements  remain 
in  a  feeble  state  of  health.  Their  circulation  is  weak  and  the 
extremities  are  cold.  The  appetite  may  be  voracious,  but  nutri- 
tion is  perverted  and  the  body  weight  is  low.  Some  of  these 
patients  will  swallow  stones,  hah,  nails,  and  other  rubbish. 
The  habits  may  be  degraded,  and  there  may  be  total  inattention 
to  the  calls  of  natm-e.  The  attitude  and  expression  of  demented 
persons  are  characteristic.  The  physiognomy  is  degenerate 
and  coarse  and  the  gait  slow  and  slouching.  Dements 
seldom  write  letters,  but,  if  they  do,  the  handwriting  wiU 
fail  to  exhibit  its  former  character.  AU  the  fine  muscular 
adjustments  are  lost,  and  movements  are  carried  out  in  a 
clumsy  manner.  In  brief,  the  patient  is  degenerate  mentally 
and  physically  ;  he  looks  degraded  ;  his  thoughts  and  actions 
are  on  a  lower  plane  than  formerly  ;  his  appetites  are  per- 
verted ;  his  sensation  is  benumbed  ;  the  lower  instincts  run 
riot,  bemg  no  longer  controlled  by  the  higher  faculties.  Once 
a  man,  he  is  now  an  intellectual  and  moral  wi'eck. 

Morbid  Anatomy  Changes. — Morbid  conditions  are  found  in 
the  membranes  and  all  the  various  tissues  of  the  brain.  The 
calvarium  is  thickened  and  more  dense  in  character.  The 
dura-mater  and  pia-arachnoid  are  thicker,  and  the  latter 
is  more  opaque.  There  is  an  increase  of  the  cerebro- 
spinal fluid.  The  cerebral  vessels  exhibit  hyahne-fibroid 
degeneration.  The  nerve-cells  are  fewer  in  number,  and  show 
degenerative  changes. 

Treatment. — AYith  careful  supervision  and  attention,  many 


170  PSYCHOLOGICAL  MEDICINE 

of  these  patients  greatly  improve.  The  bodily  health  must 
be  attended  to,  and  the  bowels  require  an  aperient  at  regular 
intervals.  If  the  appetite  is  excessive  the  meals  must  be 
supervised.  The  bowels  may  become  very  loaded  and  sickness 
may  result.  As  a  precaution  it  is  wise  to  administer  an 
aperient  once  or  twice  a  week.  Eegular  exercise  must  be 
insisted  upon  ;  bathing  and  dressing  should  take  place  under 
the  eye  of  a  nurse.  Bad  habits  must  be  corrected,  as  far  as 
possible,  and  every  endeavour  should  be  made  to  teach  the 
patient  some  useful  occupation.  In  the  milder  forms  of 
dementia,  it  fully  repays  a  nurse  or  attendant  to  take  the 
trouble  to  teach  the  patient  some  employment.  In  the  big 
asylums  the  laundry  and  workshops  are  largely  staffed  by 
demented  persons,  many  of  whom  are  found  to  be  capable  of 
doing  good  work. 

Organic  Dementia 

Organic  dementia  is  a  condition  of  mental  weakness,  the 
result  of  some  gross  disease  of  the  brain.  The  cerebral  lesion 
may  be  either  diffuse  or  localised,  and  the  extent  of  the  in- 
tellectual deterioration  largely  depends  on  the  position  of 
the  lesion.  The  mental  enfeeblement  is  merely  a  symptom  in 
the  disease  and  is  usually  later  in  developing  than  the  motor 
disturbances.  In  the  diffuse  cases,  especially  in  chronic 
diffuse  encephalitis  with  areas  of  diffuse  sclerosis,  there  is 
a  progressive  mental  deterioration  with  failure  of  memory. 
Speech  defects  may  also  be  noticeable.  These  patients  are 
usually  very  irritable  and  intolerant  of  interference,  and 
from  time  to  time  there  may  be  outbursts  of  maniacal  excite- 
ment of  a  very  unreasoning  nature.  Convulsive  attacks  are 
common,  and  they  may  be  followed  by  a  temporary  increase 
of  difficulty  in  speech.  The  pulse  is  frequent  and  low-tensioned, 
and  many  of  these  cases  die  from  exhaustion.  The  localised 
lesions  consist  chiefly  of  tumours,  hsemorrhages,  embolisms, 
thromboses,  and  abscesses.  The  later  stages  of  all  these 
conditions  are  almost  always  marked  by  some  intellectual 
change,  but  at  times  the  mental  disturbance  may  be  an 
early  and  important  symptom.  With  slowly  growing  tumours 
the  most  common  symptoms  are  an  increasing  lethargy, 
somnolence,   and   a   general   dulling   of   mentation.     In   con- 


ORGANIC  DEMENTIA  171 

versation  the  patient  is  slow  in  replying  to  questions,  and  his 
speech  is  uncertain  and  muffled.  He  fails  to  take  any  interest 
in  his  surroundings  and  seldom  expresses  his  wants. 

If,  on  the  other  hand,  the  condition  is  an  acute  one,  or 
there  is  some  sudden  alteration  in  the  intracranial  pressure, 
more  urgent  mental  symptoms  may  arise.  The  patient  may 
become  dehrious  and  restless,  and  this  condition  is  accom- 
panied by  visual  or  other  hallucinations.  Mental  symptoms 
usually  appear  earUer  with  lesions  of  the  corpus  callosum 
and  the  frontal  lobes  than  when  the  tumour  is  situated  in 
other  parts  of  the  brain.  But  it  must  be  borne  in  mind  that 
a  growth  in  the  frontal  lobes  may  exist  without  giving  rise  to 
any  morbid  psychic  phenomena.  Attempts  have  been  made 
to  localise  the  lesion  by  the  character  of  the  mental  change, 
but  the  results  have  not  been  satisfactory,  the  intellectual 
disturbances  being  by  no  means  constant  in  different  cases 
with  tumours  in  a  similar  locality.  The  rate  of  growth  is 
a  factor  of  no  little  importance  ;  a  rapidly  growing  tumour 
will  give  rise  to  many  more  mental  symptoms  than  one  of 
slow  growth.  Again,  severe  headache  may  cause  insomnia, 
and  in  an  unstable  person  this  may  lead  to  mental  disorder. 
If  the  statistics  of  these  organic  cases  are  examined,  it  will 
be  seen  that  a  very  large  proportion  of  the  patients  have  a 
neuropathic  inheritance  and  are  therefore  predisposed  to 
mental  disturbance. 

Progressive  loss  of  memory  is,  perhaps,  the  mental  symptom 
most  commonly  met  with  in  organic  lesions  of  the  brain.  In 
some  cases  the  amnesia  is  very  great  and  renders  the  patient 
totally  unable  to  look  after  himself.  He  may  offend  against 
public  decency,  not  through  conscious  transgression,  but 
through  failure  to  realise  his  whereabouts,  or  through  a 
momentary  heedlessness  of  his  surroundings.  Many  patients 
with  organic  dementia  mistake  the  identity  of  those  about 
them.  As  the  disease  runs  its  course  they  become  more  and 
more  confused,  and  finally  become  bedridden  and  hopelessly 
demented.  Cerebral  haemorrhage  may,  at  the  time  that  it 
occurs,  produce  mental  confusion.  The  memory  may  be  greatly 
affected.  A  lady  who  was  at  Bethlem  Hospital  had  several 
slight  haemorrhages,  and  on  each  occasion  her  memory  for 
the  last  fifteen  or  twenty  years  was  lost.    After  she  regained 


]  72  PSYCHOLOGICAL  MEDICINE 

consciousness  she  described  events  of  years  before  as  if  they 
had  just  happened.  In  other  cases,  there  may  be  a  severe 
emotional  disturbance  either  of  excitement  or  depression. 
Again,  patients  who  have  had  a  cerebral  hsemorrhage  may 
have  periodic  attacks  of  mania  or  melanchoha  throughout 
the  rest  of  their  life.  This  is  more  common  in  persons  whose 
mental  stabihty  is  bad.  To  sum  up  :  in  frontal  lobe  lesions  the 
patient  is  usually  irritable,  but  at  times  he  is  jovial  and  in 
the  best  of  spirits.  Loss  of  memory  and  hebetude  are  often 
prominent  symptoms. 

Tumours  of  the  corpus  callosum,  according  to  some  autho- 
rities, always  give  rise  to  mental  symptoms,  the  patient  being 
disorientated  for  time  and  place,  together  \\dth  severe  loss 
of  memory,  incoherence  of  ideas,  and  imperception,  and  a 
general  condition  of  confusion  of  mind. 

Tumours  of  the  left  angular  gyrus  and  left  temporal  lobe  lead 
to  word-blindness  and  word-deafness,  but  these  are  fully 
described  in  text-books  on  Medicine. 

Tumours  in  the  region  of  the  pituitary  body  usually  are 
associated  with  mental  depression.  The  mental  disorder, 
which  is  met  with  in  conjunction  with  cerebral  thrombosis 
and  cerebral  haemorrhage,  is  that  which  has  been  fully 
described  under  the  heading  of  Arteriopathic  Dementia. 

Physical  Symptoms. — The  physical  symptoms  are  very 
largely  those  which  are  produced  by  the  lesion,  and  it  is 
unnecessary  to  discuss  them  here.  Other  symptoms  may  occur 
which  result  from  the  altered  mental  state,  but  they  are 
similar  to  those  which  are  found  in  other  forms  of  dementia. 

Diagnosis. — The  diagnosis  can  only  be  made  from  the 
physical  signs.  The  mental  disturbance  may  be  the  first 
symptom  which  attracts  attention,  and  patients  may  be  sent 
to  an  asylum  without  the  true  cause  of  the  illness  being  recog- 
nised. Some  cases  may  be  mistaken  for  hysteria  or  general 
paralysis  of  the  insane. 

Prognosis. — The  prognosis  largely  depends  on  the  nature  of 
the  lesion  and  the  possibihty  of  its  becoming  dispersed  or 
being  surgically  removed. 

Treatment. — Treatment  is  only  possible  when  the  lesion  is 
gummatous,  or  when  operative  interference  can  be  attempted 
with  any  hope  of  success. 


173 


CHAPTEK  XII 

EPOCHAL    INSANITIES:   PUERPERAL  INSANITIES,  CLIMACTERIC 
INSANITY,  SENILE  INSANITY  AND  ARTERIOPATHIC  DEMENTIA 

Puerperal  Insanities 

Under  the  head  of  Puerperal  Insanities  will,  for  convenience, 
be  included  all  those  forms  of  mental  disorder  which  are  asso- 
ciated with  the  period  of  reproduction  in  the  female.  There 
is  no  form  of  insanity  which  is  characteristic  of,  or  special 
to,  this  period  ;  but  it  is  instructive  from  the  clinical  aspect 
to  review  the  puerperal  insanities  as  a  whole,  for  although 
they  are  similar  in  general  respects  to  those  of  other  epochs 
of  hfe,  they  are,  of  necessity,  greatly  coloured  by  the  special 
condition,  and  so  form  a  definite  group  of  their  own.  The 
exhaustion  psychoses  are  the  most  common  type,  especially 
after  the  child  is  born. 

etiology. — The  general  causes  are  similar  to  those  in 
other  forms  of  mental  disorder.  We  fkid  a  neurotic  inJieritance 
in  a  large  number  of  cases,  and  it  is  interesting  to  note  that 
in  some  instances  there  seems  to  be  a  direct  transmission  of 
a  tendency  to  break  down  at  the  reproductive  periods.  It  is 
by  no  means  uncommon  to  find  mother  and  daughter  each 
with  a  record  of  mental  disorder  during  child-bearing.  It 
may  be  that  dread  or  expectancy  plays  an  important  part  as 
a  determining  factor.  The  age  of  the  woman  is  important. 
First  pregnancies  after  thirty-two  years  of  age  are  always 
accompanied  by  risk  in  neurotic  persons.  The  writer  has 
also  seen  several  cases  of  puerperal  insanity  in  women  who, 
having  already  borne  children  earher  in  hfe,  begin  to  repro- 
duce again  after  a  lapse  of  ten  or  more  years.  Some  women 
are  more  Hable  to  break  down  when  bearing  male  children 
than  female  and  vice  versa.  A  knowledge  that  the  child  will 
be  illegitimate  is  a  potent  factor,   especially  in  the  higher 


174  PSYCHOLOGICAL  MEDICINE 

ranks  of  life.  Desertion  by  a  husband  has  been  known  to 
determine  a  mental  break-down,  and  the  death  of  a  husband, 
or  other  severe  domestic  loss,  may  lead  to  a  similar  result. 
Previous  attacks  of  insanity  predispose  to  a  recurrence  at 
this  time,  and  this  is  markedly  the  case  if  the  woman  has 
aheady  been  insane  ^\dth  former  pregnancies.  Alcoholic 
intemi^erance  and  syphilis  may  predispose  to  mental  disorder 
at  this  period.  Frequent  pregnancies  within  a  few  years 
may  occasion  serious  nutritional  disturbances  which  may 
terminate  in  insanity.  Dread  of  the  coming  suffering  may 
largely  contribute  to  a  mental  break-down.  Persistent  in- 
somnia during  pregnancy  is  always  an  anxious  symptom,  and 
may  ultimately  lead  to  profound  exhaustion  symptoms.  The 
use  of  instruments  during  labour  has  led  to  medical  men  being 
blamed  if  the  woman  breaks  doT^TL  within  a  few  days  of  the 
birth  of  the  child.  If  the  instruments  be  in  skilled  hands,  in- 
strumental labour  should  not  be  attended  by  any  such  risks. 
Many  hours  of  suffering  during  labour  may,  hy  exhaustio7i, 
produce  mental  disorder,  and  for  this  reason  a  primipara  with 
a  neurotic  inheritance  should  be  carefully  watched  if  labour  is 
prolonged,  and  either  sleep  should  be  obtained  or  instrumental 
interference  resorted  to.  Severe  haemorrhage  at  the  time  of 
the  bkth  may  determine  an  attack  of  severe  mental  disorder. 
Auto-intoxication  and  septic  conditions  probably  play  a  part 
in  a  certain  percentage  of  cases.  The  writer  beheves  that 
great  variation  in  the  general  blood-pressure,  brought  about 
by  alterations  of  direct  pressure  on  the  vessels  of  the  splanchnic 
area,  is  a  factor  of  no  small  importance  in  the  production  of 
puerperal  insanity  ;  this  subject  will  be  again  referred  to  when 
discussing  the  pathology  of  the  condition. 

Varieties. — ]\Iental  disorders  of  the  reproductive  period  are 
commonly  divided  under  three  main  heads,  viz.  :  (1)  So- 
called  insanity  of  pregnancy  ;  (2)  so-called  puerperal  insanity 
proper,  or  the  mental  disorder  which  appears  during  the  first 
six  weeks  after  the  birth  of  the  child ;  (3)  so-called  lactational 
insanity.  The  writer  has  inserted  the  word  '  so-called ' 
before  the  various  types,  as  he  wishes  to  impress  upon  the 
student  that  he  is  reading  of  no  new  variety  of  insanity. 
In  point  of  fact,  the  condition  is  usually  that  known  as 
Exhaustion  or  Confusional  Insanity. 


PUERPERAL  INSANITIES  175 

The  types  of  mental  disorder  met  with  at  these  various 
periods  are  either  melanchoKa  or  mania,  the  latter  being  more 
common  in  cases  in  which  the  break-down  occm'S  at  labour  or 
within  the  few  following  days.  During  pregnancy  the  de- 
pression may  be  quite  acute,  but  dm-ing  the  later  weeks  of 
lactation  the  sub-acute  types  of  melancholia  are  more  common. 

Mental  Symptoms. — (1)  Insanity  of  Pregnancy. — The  mental 
disorder  that  develops  during  pregnancy  is  usually  that  of 
melancholia.  The  prodromal  symptoms  may  be  merely  an 
accentuation  of  the  '  longings  '  commonly  found  in  neurotic 
persons  at  this  time.  Sleeplessness  is  an  important  symptom 
and  one  that  calls  for  energetic  treatment.  The  woman  may 
begin  to  get  over-anxious  and  worried.  The  morning  sickness 
may  be  excessive,  or  the  patient  may  misinterpret  it  and  com- 
plain that  she  is  being  poisoned,  and  so  refuse  food.  The 
depression  is  always  more  acute  in  the  morning,  and  the 
woman  should  be  watched  in  case  any  suicidal  attempt  be 
made.  She  may  take  a  dislike  to  her  husband  and  make 
unfounded  accusations  against  him.  She  may  become  apathetic 
and  indolent  and  quite  unable  to  perform  the  simplest  duties. 
Self-accusation  is  also  common  and  is  usually  accompanied  by 
suicidal  feelings.     Hallucinations  may  also  develop. 

The  insanity  of  pregnancy  has  been  subdivided  into  two 
classes,  according  to  whether  the  break-down  is  (a)  before  the 
fom'th  month,  or  (b)  after  the  fourth  month.  In  the  former 
class  the  condition  is  more  hopeful,  patients  fi'equently  recover- 
ing at  the  time  of  quickening.  Those  who  develop  mental  dis- 
order after  the  beginning  of  the  fom*th  month  do  not  usually 
recover  for  some  time  after  the  child  is  born.  This  is  an  im- 
portant point,  as  it  practically  answers  the  question  whether 
premature  delivery  should  be  resorted  to  during  the  later 
months.  Nevertheless,  it  must  be  borne  in  mind  that  the 
termination  of  pregnancy  may  at  times  become  necessary  to 
save  life,  or  in  the  early  period  to  save  a  severe  mental  break- 
down, but  surgical  interference  should  not  be  resorted  to,  if 
possible,  until  after  a  consultation  with  another  practitioner. 
There  is  an  important  medico-legal  aspect  to  puerperal  in- 
sanity. An  insane  mother  may  be  unconsciously  delivered 
and  the  child  accidentally  injured,  or  she  may  deliberately  kill, 
or  attempt  to  kill,  her  offspring. 


176  PSYCHOLOGICAL  MEDICINE 

(2)  Puerperal  Insanity. — There  may  be  a  transitory  attack 
of  acute  mania  at  the  time  of  cleliverT.  In  very  unstable 
women  the  ordinary  emotional  disturbances  may  become 
excessive.  The  excitement  usually  passes  off  when  the  child  is 
born.  Again,  immediately  after  dehvery,  within  a  few  hom's, 
there  may  be  an  outbreak  of  acute  excitement,  which  may 
last  for  some  weeks  or  may  rapidly  subside.  Any  form  of 
mental  disorder  may  develop  during  the  puerperal  period  ;  but, 
as  a  general  rule,  if  a  woman  breaks  down  within  the  first  ten 
days  or  fortnight  after  dehvery,  the  type  of  insanity  is  mania 
with  or  without  depression,  usua%  the  latter.  After  this 
time  insanity  is  more  hkely  to  be  of  a  depressive  type.  In  the 
maniacal  cases  the  excitement  is  usuaUy  very  acute.  Great 
restlessness  is  evinced,  and  food  is  refused.  The  patient  is 
noisy,  singing  and  shouting  continually.  Sordes  may  appear 
about  the  lips  and  mouth ;  the  breasts,  unless  carefuU}' 
treated,  will  become  inflamed,  and  abscesses  may  develop. 
At  times  there  is  a  marked  rise  of  temperatm-e.  Frequently 
quite  an  early  symptom  is  some  expression  of  dislike  of  the 
husband  or  nurse.  Transitory  delusions  may  show  themselves, 
and  auditory  or  visual  haUucinations  may  be  present.  There 
is  one  featm'e  in  puerperal  mania  which  calls  for  notice,  and 
that  is  that  remissions  in  the  mental  symptoms  are  frequent, 
as  is  the  case  in  aU  exhaustion  states.  A  patient  will  suddenly 
take  food  and  in  every  way  appear  to  be  normal  again.  These 
intervals  of  apparent  health  often  lead  the  friends  to  believe 
that  recovery  is  taking  place,  and  in  this  way  vigorous  and 
necessary  treatment  may  be  delayed.  These  luUs  are  soon 
followed  by  an  accession  of  the  excitement  with  all  its  accom- 
panying symptoms.  Fm'ther  details  need  not  here  be  given  ; 
the  condition  is  now  one  of  exhaustion  mania  which  has  been 
described  elsewhere. 

In  other  cases  the  emotional  state  is  one  of  depression  in  the 
place  of  excitement.  The  important  symptom  to  remember  in 
this  condition  is  the  tendency  to  suicide.  The  patient  makes 
accusations  of  all  kinds  against  herself  and  beheves  that  she 
is  unfit  to  be  a  mother.  Acute  melanchoha  of  the  ordinary 
exhaustion  type  may  be  met  with  during  the  puerperal 
period  ;  it  commonly  develops  about  three  weeks  after  de- 
livery.    During  recent  years  there  have  been  several  cases  of 


PUERPERAL  INSANITIES  177 

general  paralysis  of  the  insane  reported,  in  which  the  first 
symptoms  declared  themselves  during  the  puerperal  period. 
In  these  cases  the  stress  of  child-bearing  seems  to  be  the  final 
exciting  cause ;  but  except  for  their  bearing  upon  diagnosis, 
they  do  not  call  for  special  mention. 

The  course  of  the  above  disorders  will  be  dealt  with  later. 

(3)  Insanity  of  Lactation. — This  has  been  arbitrarily  fixed 
as  comprismg  those  insanities  which  appear  six  weeks  or 
more  after  dehvery.  The  mental  disorder  is  usually  of  the 
type  of  subacute  melanchoHa  with  ideas  of  unworthiness. 
Suicidal  attempts  and  infanticide  are  common.  Some  autho- 
rities have  divided  these  cases  into  two  classes  :  (a)  those  in 
which  insanity  develops  while  the  mother  is  still  nursing  the 
child  ;  (b)  those  in  which  the  mental  disorder  follows  imme- 
diately upon  weaning.  The  mental  distm'bance  in  the  first 
class  is  largely  the  result  of  the  physical  exliaustion  from 
suckling,  for  with  weaning,  careful  feeding,  and  rest,  health 
is  soon  restored.  On  the  other  hand,  in  the  cases  belonging  to 
the  second  division,  the  insanity  is  more  persistent  and  often 
runs  a  longer  course.  Delusions  of  any  kind  may  occur  and 
are  similar  to  those  found  in  the  melanchoHa  of  other  periods 
of  Hfe.  The  reader  should  again  be  reminded  of  the  medico-legal 
aspect,  which  may  become  an  important  feature  at  any  time. 

Physical  Sjnnptoms. — (1)  Insanity  of  Pregnancy. — The  physical 
symptoms  are  largely  those  fomid  in  melancholia,  together 
with  the  more  special  symptoms  due  to  the  pregnancy. 
Most  women,  and  especially  those  of  the  neurotic  type, 
have  altered  appetites  during  cliild-bearmg.  The  question 
of  feeding  is  often  a  difficult  one,  for  proper  food  may  be 
refused.  Constipation  is  a  symptom  which  constantly  requires 
attention.  It  must  be  borne  in  mind  that  an  insane  person 
may  not  complain  of  pain  or  discomfort  in  the  same  Avay 
that  her  sane  sister  would  do  ;  it  is  therefore  the  more  incum- 
bent on  the  nurse  to  watch  for  symptoms  such  as  retention  of 
urine,  varicose  veins,  severe  oedema  of  the  legs,  and  the  like, 
reporting  them  to  the  medical  attendant  as  soon  as  observed. 
Insomnia  may  be  an  urgent  symptom  and  should  always  be 
treated  when  the  patient  is  at  all  neurotic.  When  the  time 
of  dehvery  is  near,  special  care  must  be  taken  ;  for  if  the 
woman  is  very  msane,  she  may  not  complain  of  the  labour  pains. 

12 


178  PSYCHOLOGICAL  MEDICINE 

(2)  Puerperal  Insanity. — The  physical  symptoms  at  this 
time  are  often  many  and  important,  and  there  is  a  danger  of 
their  bemg  overlooked  when  the  mental  symptoms  are  severe. 
Nm'ses  are  at  times  apt  to  forget  their  ordmary  duties  when 
suddenly  confronted  with  mental  disorders.  When  a  child  is 
weaned,  the  breasts  demand  regular  and  careful  treatment ; 
if  they  are  neglected,  an  abscess  may  form  in  a  very  short 
space  of  time.  Eetention  of  urine  is  another  very  urgent 
S3^mptom.  The  condition  of  the  lochial  discharges  must  be 
watched  and  reported  on.  The  lochia  may  be  arrested  or 
become  offensive,  especially  in  septic  cases,  but  as  a  general 
rule  these  discharges  follow  a  normal  course.  The  bowels 
are  usually  constipated  and  purgatives  are  constantly  required. 
The  physician  should  warn  the  nurse  to  examine  the  patient 
morning  and  evening  for  the  ordinary  compHcations  which 
may  occm*  at  this  time.  The  temperature  should  be  regu- 
larly taken,  as  fever  may  be  the  first  symptom  of  some  lung 
disorder  or  of  a  local  abscess.  Eigors  occur  but  are  not 
common.  Convulsions  may  occm'  in  rare  cases.  The  tongue 
is  usually  dry,  and  sordes  form  about  the  lips  and  mouth. 
Nutritional  changes  may  take  place  in  the  skin  and  its  appen* 
dages  ;  small  local  inflammations  and  abscesses  are  common. 
The  pulse  is  frequent  and  low-tensioned.  In  severe  cases  the 
woman  may  pass  into  a  low-muttering  dehrium  closely  re- 
sembling the  typhoid  state.  Most  patients  rapidly  lose  weight, 
and  forced  feeding  is  often  necessary. 

(3)  Insanity  of  Lactation. — The  physical  symptoms  de- 
pend largely  on  the  form  of  mental  disorder.  We  have 
already  pointed  out  that  subacute  depression  is  the  most 
common  variety,  and  accordingly  the  bodily  symptoms  are 
largely  those  seen  in  melancholia.  There  may  be  great  ex- 
haustion from  prolonged  suckling — thus  rest  and  forced  feeding 
are  indicated. 

Course. — (1)  Insanity  of  Pregnancy. — We  have  already 
stated  that  those  patients  who  break  down  before  the  fourth 
month  of  pregnancy  usually  recover  before  the  birth  of  the 
child.  Li  the  cases  where  the  insanity  does  not  develop  until 
the  later  months  there  may  be  some  temporary  improvement  at 
the  time  of  delivery  ;  relapse  is,  however,  common,  and  many 
remam  insane  for  some  months  longer. 


PUERPERAL  INSANITIES  179 

(2)  Puevperal  Insanity. — The  course  varies  according  to 
the  severity  of  the  attack.  In  the  severe  forms  the  patient 
may  pass  into  an  acute  delirious  condition.  If  death  does 
not  supervene,  the  physical  health  improves  after  a  few  weeks 
and  the  excitement  becomes  less  marked.  The  maniacal  state 
may  be  followed  by  a  period  of  stupor  or  general  apathy. 
The  latter  condition  may  last  for  months,  but  passes  on  to 
recovery  ;  more  rarely  the  delusions  and  hallucinations  may 
persist,  in  which  case  there  is  a  tendency  for  the  patient  to 
become  weak-minded.     Many  patients  recover  rapidly. 

(3)  Insanity  of  Lactation. — The  course  is  usually  one  of 
progressive  improvement  in  the  case  of  those  who  break  down 
from  stress  of  suckling;  but  where  there  is  marked  failure 
of  physical  health  the  course  is  often  long  and  tedious. 
Depression,  with  inability  to  do  ordinary  duties  and  a  ten- 
dency to  suicide,  may  last  for  some  months. 

Diagnosis. — The  diagnosis  of  mental  disorder  during  preg- 
nancy is  not  always  easy.  As  already  stated,  the  symptoms 
may  merely  be  an  accentuation  of  the  '  longings  '  so  com- 
monly seen  in  pregnant  women.  These  patients  are  often 
fanciful,  and  even  emotional  at  times,  thus  further  increasing 
the  difficulty. 

The  diagnosis  of  certifiable  insanity  largely  depends  on 
the  conduct  of  the  patient.  The  danger  of  suicide  must  never 
be  forgotten.  Dming  the  true  puerperal  period  immediately 
subsequent  to  the  biith  of  the  child,  insanity  may  have  to  be 
distinguished  from  temporary  delirium  due  to  a  septic  fever. 
The  latter  is  usually  ushered  in  by  rigors  and  fever  with 
suppression  of  the  lochia.  Even  temporary  delirium  may 
pass  on  to  a  more  permanent  excitement  or  to  acute  delirious 
mania.  With  the  delirious  forms  the  condition  is  a  very 
serious  one,  and  many  of  the  patients  die. 

Prognosis. — The  prognosis  is  decidedly  good  for  patients 
who  break  down  during  the  early  months  of  pregnancy  ;  but, 
although  favourable,  it  is  by  no  means  so  good  for  those  who 
develop  mental  disorder  during  the  later  months.  In  the 
favourable  cases  of  the  latter  class,  recovery  does  not  usually 
take  place  until  some  time  after  delivery ;  about  one-third  of 
the  cases  of  this  class  remain  chronically  insane.  For  those 
who  become  insane  after  delivery  it  is  a  good  working  rale 


180  •  PSYCHOLOGICAL  MEDICINE 

to  say  that  the  nearer  the  break-down  is  to  the  bhth  of  the 
child,  the  better  is  the  prognosis.  Patients  who  develop 
insanity  during  the  first  few  days  after  delivery  nearly  always 
get  well.  Acute  delirious  cases  must  be  excepted  from  this 
general  rule,  as  a  large  percentage  of  these  patients  die. 
Insanity  developing  during  the  later  months  of  lactation  is 
often  subacute  in  character  and  tends  to  run  a  long  course. 
Many  patients  may  partially  recover  in  asylums,  but  have  to 
be  sent  home  for  the  cm'e  to  be  completed.  When  these 
puerperal  patients  get  well  they  usually  keep  well  and  may 
never  have  a  return  of  mental  disorder,  provided  they  have 
no  more  children. 

Pathology  and  Morbid  Anatomy. — As  the  mental  disorder 
is  largely  the  result  of  exhaustion  the  reader  is  referred 
to  the  pathology  and  morbid  anatomy  of  this  condition. 
The  writer  thinks  that  variation  in  the  general  blood-pressure 
may  probably  be  an  important  element  in  the  production  of 
the  mental  disorder.  AATien  it  is  realised  that  during  preg- 
nancy the  pressure  on  the  splanchnic  vessels  is  steadily  in- 
creased, it  seems  likely  that  this  may  affect  the  cerebral  blood 
supply,  and  that  resulting  nutritional  changes  may  lead  to 
mental  disorder  in  unstable  persons.  With  increased  blood* 
pressm'e  we  should  expect  to  find  the  patient  inclined  to  be 
depressed,  and  this  is  the  case,  as  melancholia  is  the  common 
type  of  mental  disorder  found  at  this  time.  On  the  other  hand; 
after  labour,  when  there  is  a  sudden  withdrawal  of  pressure 
on  the  splanchnic  vessels,  there  is  in  consequence  a  rapid  fall 
in  the  blood-pressm-e,  and  accordingly  we  should  expect  to 
find  a  tendency  to  mania  in  the  predisposed  person.  Now  this 
is  what  does  take  place,  for  restlessness  and  states  of  excite- 
ment are  the  types  of  mental  disorder  prevalent  at  this  period. 

Treatment. — The  treatment  of  any  given  case  varies 
according  to  the  type  of  the  mental  disorder,  and  the  reader  is 
referred  to  the  chapters  dealing  with  these  special  forms  of 
disease. 

As  a  prophylactic  measure  it  is  important  to  keep  up  the 
blood-pressure  at  the  time  of  the  birth  of  the  child,  when  the 
patient  ls  a  neurotic  subject.  This  can  be  done  by  pressm'e 
or  by  the  judicious  use  of  pituitrin.  The  administration  of 
calcium  salts  is  very  helpful  in  treating  these  cases. 


CLIMACTERIC  INSANITY  181 

Climacteeic  Insanity 

There  is  no  form  of  mental  disorder  that  can  be  properly- 
termed  climacteric  insanity  ;  but  from  the  clinical  aspect  it  is 
well  to  review  the  varieties  of  mental  disturbance  met  with 
at  this  epoch.  At  the  menopause  the  individual  undergoes 
a  profound  change,  both  mentally  and  physically,  and  in  a 
person  predisposed  to  insanity  serious  results  may  ensue. 
At  the  climacteric  mental  life  becomes  slower  ;  there  is  a 
lessening  of  the  sexual  desire,  and  the  affections  change.  It 
is  the  beginning  of  decadence.  Even  in  this  country,  with  its 
greater  accuracy  of  statistical  data,  it  is  difficult  to  fix  with 
precision  the  cHmacteric  years  ;  but  they  may  fairly  be  said 
to  range  between  the  ages  of  forty-three  and  fifty-one. 

etiology. — As  in  the  mental  disorders  of  other  periods  of 
life,  an  unstable  inheritance  plays  an  important  part  in  the 
production  of  insanity.  A  neurotic  history  is  found  in  about 
fifty-four  per  cent,  of  the  cases.  Married  women  are  more 
frequently  affected  than  single  women  in  the  proportion  of 
fifty-five  to  forty-five.  Governesses  and  others  who  have  to 
work  hard  for  their  hving  seem  to  be  especially  hable  to  mental 
disorder  at  this  time.  It  is  not  so  much  hard  work  as  unsuc- 
cessful work  that  excites  disturbance.  The  worry  and  anxiety 
of  Imowing  that  no  provision  has  been  made  for  old  age, 
privation,  ill-health,  and  physical  disease  ^are  all  important 
causes.  Previous  attacks  of  insanity  during  earher  periods  of 
life  render  a  woman  more  liable  to  a  mental  break-down  at 
the  menopause.  Excessive  loss  or  '  flooding  '  may  lead  to 
exhaustion  types  of  mental  disorder,  in  fact  in  the  writer's 
experience  menorrhagia  and  metrorrhagia  are  at  all  times 
potent  causes  of  nerve  exhaustion  and  even  more  especially  so 
at  the  period  under  review.  Further,  arterio-sclerotic  degene- 
ration may  begin  to  declare  itself  at  or  during  the  next  few 
years  following  the  menopause,  and  many  cases  occurring  at 
this  time  are  of  this  type. 

Forms  of  Insanity. — As  we  have  already  remarked,  there  is 
no  special  insanity  peculiar  to  this  period.  Most  authorities 
agree  that  states  of  depression  are  more  common  than  any 
other  form  of  mental  disorder.  The  melanchoKa  is  usually  of 
a  subacute  type,  though  at  times  the  patient  is  restless  and 


182  PSYCHOLOGICAL  MEDICINE 

agitated.  Maniacal  and  chronic  delusional  states,  though 
less  frequent,  are  by  no  means  rare.  As  above  stated,  the 
exhaustion  psychoses  and  arteriopathic  dementia  are  both 
commonly  seen  during  this  period  of  life.  Cases  of  general 
paralysis  have  also  been  reported. 

Prodromal  Symptoms. — The  mental  alterations  and  somatic 
disturbances  frequently  exhibited  by  the  apparently  healthy 
woman  at  the  menopause  may  be  the  prodromata  of  actual 
insanity.  Among  the  mental  disturbances  we  may  mention 
the  following,  viz.  insomnia,  failure  of  attention,  alteration 
of  temper,  irritabihty,  changed  affection  towards  husband, 
suspicions,  jealousies,  and  at  times  a  tendency  to  make  false 
accusations.  Some  women  have  difficulty  in  performing  their 
usual  household  duties.  Groundless  fears  and  waves  of 
mental  depression  sometimes  occur.  Sexual  perversions  are 
not  uncommon.  Noises  in  the  ears  and  temporary  deafness 
are  frequent  symptoms.  At  this  period  there  is  a  tendency 
to  be  introspective  and  hypercritical  in  the  view  of  actions 
of  earHer  hfe.  Among  the  somatic  disorders  those  referable 
to  the  vascular  system  are  prominent :  general  flushings, 
congestion  of  the  head,  and  giddiness.  Gastro-intestinal  dis- 
turbances are  common.  The  growth  of  hair  on  the  face, 
which  has  been  remarked  at  this  period,  is  noteworthy  in 
association  with  the  disappearance  of  the  reproductive 
functions.  The  vagaries  of  the  menstrual  functions  at  this 
epoch  are  well  Imown  ;  gradual  cessation,  with  irregularities  in 
quantity  and  periodicity,  or  sudden  cessation.  Drunkenness 
in  women  in  England  and  Wales  has  been  shown  to  be  more 
common  at  this  time  than  at  any  other  epoch  of  life.  Habits 
of  all  kinds  are  easily  acquired,  as  it  seems  to  be  a  period  of 
exaggerated  '  suggestibility.'  Care,  therefore,  should  be  exer- 
cised in  regard  to  the  use  of  a  drug  such  as  morphia.  Medical 
men  are  often  blamed  for  habits  so  formed,  and  sometimes  with 
justice. 

Mental  Symptoms. — The  mental  symptoms  are  mainly  a 
continuation  and  elaboration  of  the  prodromata  and  are,  of 
course,  those  described  in  the  various  types  of  nervous  dis- 
order, any  one  of  which  the  patient  may  be  suffering  from  ; 
i.e.,  nerve  exhaustion,  maniacal-depressive,  arteriopathic  de- 
mentia, etc.     Groundless  fears  may  begin  to  haunt  the  woman. 


CTLIMACTERIC  INSANITY  183 

More  and  more  she  feels  unable  to  cope  with  her  daily  work. 
Self-acciisation  of  all  kinds,  with  reference  to  things  both  past 
and  present,  begins  to  occupy  the  whole  of  her  attention. 
Slowly  she  weaves  her  story,  always  ignoring  evidence  opposed 
to  her  beliefs,  but  readily  embracing  all  that  supports  them. 
The  patient  fails  to  realise  that  she  is  ill,  the  very  nature  of 
her  malady  preventing  her  from  grasping  her  true  condition. 
It  is  the  old  story,  '  what  I  feel  must  be  true  '  ;  cold  reasoning 
is  impossible  in  the  presence  of  such  conclusive  evidence  from 
the  senses. 

Delusions  of  every  kind  may  develop.  The  conscientious 
woman  at  once  condemns  herself  under  the  belief  that  she 
-is  forsaken  of  her  God,  and  her  delusions  are  strongly 
tinged  with  a  rehgious  colouring.  Another  patient  lays 
more  stress  on  her  physical  symptoms  and  misinterprets 
these.  The  abdominal  sensations  may  be  construed  into 
ideas  of  pregnancy  ;  or  the  anomalous  cutaneous  sensations 
may  form  the  basis  of  delusions  of  electricity.  Another 
believes  that  her  husband  is  losing  interest  in  her  ;  she  feels 
a  sense  of  neglect  and  seeks  for  an  explanation.  The  idea 
that  he  cares  for  another  begins  to  creep  in  and  gradually 
establishes  itself.  Worthless  evidence  of  infideUty  is  accepted  ; 
suspicions  and  jealousies  increase,  and  finally  culminate  in 
some  charge  of  unfaithfulness.  These  ideas  are  of  no  small 
consequence,  as  serious  medico-legal  questions  have  arisen 
from  such  delusions.  The  accuracy  of  the  woman's  state- 
ments should  be  carefully  tested,  and  her  mental  condition 
should  be  thoroughly  examined.  Full  notes  should  be  taken 
at  the  time,  and  a  consultation  with  a  second  medical  man  is 
advisable. 

On  the  other  hand,  a  woman  may  make  a  confession 
that  she  is  guilty  of  some  crime,  whereas  in  point  of  fact 
her  sin  is  merely  the  creation  of  her  disordered  brain.  The 
delusions  of  a  woman,  more  especially  if  she  be  unmarried, 
may  take  the  form  of  believing  that  a  certain  man  desires  to 
marry  her.  She  may  go  so  far  as  to  say  that  the  man  has 
actually  proposed  marriage  ;  or  she  may  excuse  his  bashful- 
ness  and  content  herself  with  the  assurance  of  his  feeling 
towards  her,  confident  that  love  such  as  his  needs  no  ex- 
pression— '  I   know  that    he   loves   me  '    is   enough   for   her. 


184  PSYCH0L0C4ICAL  MEDICINE 

and  she  acts  accordingly.  Such  a  person  has  no  shame  ;  but 
as  it  is  her  conduct  rather  than  her  conversation  wliich  is  at 
fault,  it  is  often  very  difficult  to  certify  her  as  insane. 

In  conclusion,  delusions  of  persecution  of  almost  every 
kind  may  be  met  with.  Some  women  beheve  that  they  are  the 
victims  of  a  foul  conspiracy,  and  that  their  fair  name  is  being 
defamed.  Others  beheve  that  they  are  being  '  followed,'  or 
that  their  thoughts  are  read.  Hallucinations  are  frequently 
present,  those  of  the  auditory  and  visual  types  being  the  most 
common.  Some  authorities  lay  great  stress  on  olfactory 
hallucinations  and  beheve  that  they  are  closely  related  to 
ovarian  disease.  The  writer  does  not  thmk  that  this  is  sup- 
ported by  either  clinical  or  post-mortem  evidence.  In  any  case 
it  is  certainly  desirable  that,  until  symptoms  of  ovarian  disease 
become  clear,  no  resort  should  be  had  to  surgical  interference 
or  even  less  severe  methods.  The  risks  of  suicide  must  not 
be  lost  sight  of  ;  and  it  is  of  interest  to  note  that  statistics 
show  that  suicide  in  women  is  most  common  between  the  ages 
of  forty  and  fifty. 

Physical  Symptoms. — The  physical  symptoms  are  an  elabo- 
ration of  those  already  described  under  Prodromata.  They 
largely  depend  upon  the  forms  of  mental  disorder  with  which 
they  are  associated.  Usually  there  is  a  general  nutritional 
disturbance  which  affects  all  the  systems  and  is  similar  to 
that  found  in  melanchoha. 

Course. — The  course  that  the  illness  follows  is  to  a  great 
extent  dependent  upon  the  type  of  mental  disorder.  If  it  is 
sub-acute  melanchoha,  the  duration  is  a  long  one,  extending 
over  eighteen  months  or  two  years.  The  symptoms  may 
increase  in  severity  in  the  earher  months,  and  asylum  treat- 
ment is  often  necessary.  The  various  courses  'of  the  disorders 
have  been  described  imder  the  different  forms  of  insanity 
given  in  former  chapters. 

Diagnosis. — Amenorrhoea  is  a  common  symptom  in  most 
forms  of  acute  insanity,  and  care  must  be  taken  not  to  confuse 
the  menopause  with  amenorrhoea  occurring  during  an  ordinary 
attack  of  insanity  in  a  woman  under  forty-five  years  of  age. 

Prognosis. — This  is  fairly  good  if  the  case  is  treated  early, 
and  if  the  type  of  nervous  disturbance  is  not  due  to  arterio- 
sclerotic degeneration  ;    but  if  allowed  to  drift,  the  condition 


CLIMACTERIC  INSANITY  185 

frequently  becomes  chronic  owing  to  the  habits  of  thought 
and  action  the  patient  may  form  dm'ing  the  acute  stage  of  the 
ilhiess.  If  recovery  does  take  place,  there  may  never  be  a 
return  of  any  mental  disorder,  except  in  those  cases  in  which 
there  have  been  attacks  before  the  menopause.  With  regard 
to  the  influence  of  the  climacterium  on  existing  psychoses, 
experience  does  not  justify  the  hope  that  improvement  will 
occur  in  the  mental  condition  of  those  persons  who  have 
been  ill  for  some  months  or  years  before  the  menopause. 
These  persons  usually  continue  insane  after  the  climacteric  is 
passed. 

Pathology  and  Morbid  Anatomy. — There  is  no  change  which 
can  be  looked  upon  as  characteristic  of  climacteric  in- 
sanity. Some  authorities  consider  that  the  condition  is  one 
of  prematm-e  seniUty.  Probably  auto-intoxication  is  a  factor 
of  great  importance.  The  writer  believes  that  owing  to  the 
vaso-motor  disturbances  which  are  common  at  this  time,  the 
general  blood-pressure  is  markedly  affected,  and  that  in  this 
way  the  cerebral  nutrition  suffers.  Under  these  circumstances 
it  is  clearly  the  predisposed  and  unstable  individuals  who 
will  be  most  liable  to  develop  mental  disorder. 

Treatment. — When  symptoms  which  may  be  the  prodromata 
of  insanity  appear  at  the  climacteric  period  in  patients  with 
an  unstable  inheritance  or  a  history  of  a  previous  attack, 
prophylaxis  of  a  general  kind  should  be  adopted.  Best  and 
good  feeding  are  indicated.  At  this  time  women  frequently 
consult  medical  men  concerning  obscure  symptoms  in  the 
region  of  the  uterus  and  its  appendages,  and  not  uncommonly 
receive  local  treatment.  Such  measures  are  to  be  deprecated, 
as  they  tend  to  an  undesirable  self-concentration,  and  may 
ultimately  convert  the  patient  into  an  hypochondriacal  invalid. 
If  there  is  menorrhagia  or  metrorrhagia  the  writer  has  found 
great  help  by  the  administration  of  styptol.  The  treatment 
of  climacteric  insanity  is  that  of  melancholia  or  such  other 
form  of  insanity  as  the  mental  disorder  may  assume.  The 
earlier  the  treatment,  the  greater  is  the  likelihood  of  recovery. 
Kemoval  from  home  surroundings  is  usually  advisable,  and 
is  necessary  in  those  cases  in  which  unreasoning  suspicion 
and  jealousy  characterise  the  insanity. 


186  PSYCHOLOGICAL  MEDICINE 

Senile  Insanity  and  Aeteriopathic  Dementia 

Mental  disorder  may  develop  at  any  period  of  life,  and 
senility  is  no  more  exempt  than  other  epochs.  The  term  '  senile ' 
is  necessarily  relative,  for  one  man  must  be  looked  upon  as  old 
and  decrepit  when  another,  his  equal  in  age,  is  still  apparently 
in  his  prime.  'A  man  is  as  old  as  his  arteries  '  aptly  sums 
up  the  situation  ;  one  man  reaches  the  years  of  decadence 
before  another,  owing  to  serious  nutritional  and  degenerative 
changes  taking  place  earlier  in  the  arteries  and  other  tissues 
of  his  body.  Atrophy  and  decay  is  the  natural  ending  of  all 
forms  of  life.  The  time  of  the  appearance  of  these  indica- 
tions of  dissolution  varies  within  wide  Hmits,  which,  however, 
are  regulated,  apart  from  disease,  by  a  well-established  funda- 
mental law.  Organisations  which  matm'e  rapidly  and  reach 
their  fuU  development  in  a  comparatively  short  time,  tend 
likewise  to  decay  early.  So  it  is  with  the  mental  and  physical 
aspects  of  human  life.'  In  tropical  coimtries,  where  meta- 
boUsm  is  active,  the  female  is  akeady  reproducing  her  species 
while  her  contemporary  in  years,  residing  in  a  more  temperate 
chmate,  is  stiU  in  the  nursery.  But  the  slower  development 
observed  in  the  northern  latitudes  in  the  end  proves  its 
superiority,  for  it  carries  with  it  a  longer  period  of  matm'ity. 
Mental  life,  in  its  evolution  and  decay,  closely  resembles  the 
physical :  mental  powers  which  are  precocious  and  mature 
rapidly  tend  to  early  degeneration.  This  truth  enforces  itself 
in  the  observation  of  many  forms  of  mental  disorder. 

etiology. — A  nem'otic  inheritance  is  found  in  a  fait"  per- 
centage of  cases  of  senile  insanity,  but  clearly  an  unstable 
inheritance  must  be  a  far  less  potent  factor  in  old  age  than 
in  youth.  On  the  other  hand,  previous  attacks  during  earlier 
life  are  important  as  predisposing  to  an  attack  of  mental  dis- 
order when  senility  is  reached. 

Organic  cerebral  disease  may  be  the  exciting  cause.  Care- 
ful distinction  must  be  drawn  between  insanity,  the  result  of 
organic  brain  change,  and  the  so-called  functional  psychoses 
which  may  appear  during  senility  in  the  same  Avay  as  they  do 
at  any  other  period  of  life.  Uraemia  and  other  toxic  influences, 
such  as  alcoholism,  maj^  be  the  exciting  causes  of  mental  disease 
duiing  old  age.     Anything  which  leads  to  n^alnutrition  and 


SENILE  INSANITY  187 

slow  progressive  degeneration  of  the  brain  must  be  included 
among  the  ^etiological  factors. 

Varieties  o£  Insanity. — There  is  no  form  of  mental  dis- 
order which  can  be  properly  termed  senile  insanity,  but 
many  types  of  disorder  may  be  met  with  in  old  age.  For  con- 
venience, it  is  better  to  divide  these  mental  diseases  into  two 
main  classes  :  (a)  the  so-called  functional  or  temporary  'psychoses  ; 
(h)  arteriopathic  dementia.  This  is  not,  it  need  scarcely  be  said, 
advanced  as  a  scientific  method  of  classification,  for  probably 
all  cases  show  some  organic  change.  It  is,  however,  convenient, 
for  in  the  fmictional  psychoses  may  be  included  those  forms  of 
mental  disorder  which  are  curable,  and  which  resemble  the 
insanities  of  earher  life.  The  organic  cases  are  those  suffering 
from  slow  and  progressive  senile  brain  changes. 

Mental  Symptoms. — These  vary  according  to  the  forms  of 
mental  disorder.  The  early  symptoms  both  of  the  functional 
and  organic  psychoses  are  failure  of  power  of  application  for 
concentrated  thought,  general  irritability  and  restlessness,  loss 
of  body  weight,  and  increasing  sleeplessness.  With  the 
organic  forms,  failure  of  memory,  more  especially  for  recent 
events,  is  a  prominent  symptom.  A  brief  description  of  the 
types  most  commonly  met  with  in  old  age  follows. 

Functional  Psychoses. — (a)  MelancJwlia. — Depression  is 
by  no  means  uncommon.  The  patient  has  vague  fears  of 
ruin  ;  he  cannot  attend  to  his  business  as  he  used  to  do  ; 
younger  men  seem  always  to  compete  successfully  mth  him  ; 
he  accuses  himself  of  neglect ;  he  remembers  that  many 
years  ago  he  borrowed  some  stamps  from  his  firm  and  never 
replaced  them,  and  he  argues  from  this  that  he  must  have 
defrauded  his  partners.  He  rakes  up  early  errors  and  magni- 
fies them  into  criminal  deeds.  He  beheves  that  he  has  brought 
ruin  and  disgrace  on  his  family  and  that  he  must  end  his 
days  in  prison.  Another  patient  develops  hypochondriacal 
ideas  ;  he  believes  that  his  body  is  being  slowly  consumed 
by  some  baneful  disease,  that  his  abdominal  viscera  are  loaded 
with  excreta,  and  that  the  normal  functions  of  the  body  are 
no  longer  performed.  The  most  common  delusions  are  those 
stated  above,  but  almost  any  form  of  false  behef  may  be 
met  with  in  senile  melancholia.  Hallucinations  and  illusions 
are  found  in  some  cases.     Suicidal  tendencies  are  as  a  rule 


188  PSYCHOLOGICAL  MEDICINE 

prominent,  attempts  at  self-destruction  being  frequent.  Many- 
aged  persons  exhibit  serious  homicidal  tendencies,  and  this 
symptom  may  occur  in  both  the  fmictional  and  organic  forms 
of  mental  disorder  observed  during  seniHty, 

(h)  Mania. — A  general  feeling  of  well-being  may  be  an 
early  symptom  in  senile  insanity.  This  is  usually  ushered  in 
by  a  short  period  of  increased  activity  and  sleeplessness. 
States  of  mild  excitement  in  the  senile  may  have  a  very 
important  medico-legal  aspect.  Old  men — always,  be  it  re- 
membered, a  relative  term — who  have  lived  honourable  and 
honoured  lives  may  offend  against  the  moral  and  social  laws 
by  some  sexual  act.  Just  as  control  is  an  attribute  of  late 
development,  so  it  fails  early  with  dissolution.  Sexual  in- 
discretions in  these  cases  are,  as  a  general  rule,  due  rather 
to  loss  of  control  or  to  impulse  than  to  any  criminal  intent. 
The  offences  vary  from  obscene  talk  and  acts  to  more  serious 
crimes,  though  the  latter  are  comparatively  rare.  Commonly 
the  acts  are  so  foolish  and  childish  that  one  would  have  thought 
even  the  mind  untrained  in  mental  disease  would  see  that 
they  bore  upon  them  the  stamp  of  senile  deterioration.  A 
proper  undertaking  from  the  relatives  of  the  patient  to  safe- 
guard society  from  any  further  scandal  or  harm,  or  at  most 
an  order  for  detention  in  an  ordinary  asylum,  might  reason- 
ably be  thought  to  meet  the  demands  of  justice.  Unhappily 
our  law  does  not  permit,  or  its  administrators  always  sanction, 
this  view.  It  may  be  through  defect  in  the  law  itself  that 
a  course  which  the  larger  justice  of  scientific  experience 
suggests  is  not  taken.  If  that  be  so,  the  remedy  is  by  legis- 
lation. There  is,  however,  ground  for  supposing  that  some- 
times the  fault  lies  in  the  deficient  scientific  knowledge  of  the 
administrators  of  the  law.  It  may  be  inevitable  in  the  present 
state  of  our  law  that  an  old  man,  whose  every  action  of  his 
healthy  life  has  redounded  to  his  credit,  should  be  dragged 
through  the  criminal  courts  in  his  hfe's  decay  ;  and  until 
some  change  ])e  made  in  the  cumbrous  machinery  of  ad- 
ministration, this  is  perhaps  to  be  expected,  though  it  may  well 
be  deplored.  There  is,  however,  no  excuse  for  the  ignorance 
of  established  facts  of  mental  science  which  awards  to  the 
poor  victim  of  his  mortality  some  severe  sentence  of  imprison- 
ment.   Even  if  it  be  necessary  in  the  interests  of  society  not 


SENILE  INSANITY  189 

to  make  too  fine  a  distinction  between  vice  and  insanity,  some 
exception  might  fairly  be  looked  for  where  senility  lapses  into 
crime.  Character  changes  in  decay  ;  to  punish  an  old  man 
for  an  offence  which  from  failure  of  control  he  has  committed, 
is  to  punish  him  for  being  mortal.  It  is  in  the  treatment  of 
these  senile  delinquents  that  the  inefficiency  of  the  present 
methods  of  trying  cases  involving  issues  of  sanity  or  responsi- 
bility is  glaringly  apparent.  It  may  occur  that  the  position 
and  means  of  the  offender  permit  the  calling  of  eminent  special- 
ists in  mental  disease  on  his  behalf.  If  they  are  successful 
in  winning  the  Court  to  a  reasonable  view  of  insanity,  the 
luckless  prisoner  may  hope  to  end  his  days  in  such  comfort 
and  dignity  as  a  criminal  lunatic  asylum  may  afford.  Too 
often  the  plea  of  insanity  or  irresponsibility  cannot,  by  reason 
of  the  poverty  of  the  prisoner,  be  properly  enforced.  In 
that  case  an  honourable  life  may  close  in  the  dishonour  of  a 
common  gaol. 

In  the  chapter  on  Testamentary  Capacity  attention  has 
been  drawn  to  the  want  of  a  properly  constituted  Court,  such 
as  a  judge  and  two  medical  assessors,  to  try  '  will '  suits. 
Some  such  tribunal  might  far  more  suitably  than  the  con- 
ventional tribunal  try  a  number  of  cases  of  other  kinds,  in- 
volving issues  requiring  special  medical  knowledge  for  their 
due  treatment. 

From  the  above  observations  the  physician  will  appreciate 
how  important  it  is  that  relatives  should  be  warned  to  exer- 
cise careful  supervision  over  a  man  who  in  any  way  show^s  a 
tendency  to  excitement.  A  serious  difficulty  is  that,  until 
he  has  once  offended,  it  is  not  easy  to  treat  him  on  mere 
suspicion.  To  return  to  the  broader  aspect  of  the  subject, 
a  senile  person  may  have  definite  attacks  of  acute  mania  ; 
he  may  be  incoherent,  noisy,  and  irritable  ;  and  at  times 
delusions  and  hallucinations  may  be  present.  A  tendency  to 
mistake  identity  is  a  frequent  symptom.  The  excitement  may 
be  intense,  with  severe  insomnia,  and  may  lead  to  exhaustion 
and  death.  Patients  with  senile  mania  are  always  restless  ; 
they  frequently  stand  and  shout  at  their  bedroom  door  all 
night.  Kefusal  of  food  may  be  an  important  symptom  and 
is  always  one  that  requires  careful  attention. 

Arteriopathic  Dementia. — This  form  of  dementia  is  common 


190  PSYCHOLOGICAL  MEDICINE 

in  persons  of  sixty  years  of  age  and  upwards  ;  but  at  times  it  is 
met  with  earlier  in  those  who  have  hved  a  hard  hfe,  or  are 
alcoholic,  or  who  have  had  syphilis,  as  the  latter  may  cause 
cerebral  endarteritis  or  atheroma  and  in  consequence  a  pre- 
mature senility. 

The  mental  symptoms  are  often  insidious  at  the  onset. 
Irritability  and  restlessness  may  first  be  noticed.  Headaches 
and  vertigo  may  be  complained  of.  The  memory  becomes 
uncertain.  Thought  may  be  slow  and  the  movements  slovenly. 
The  mental  attributes  usually  fail  in  the  inverse  order  to  that 
in  w^hich  they  w^ere  acquired.  The  power  of  perception  begins 
to  be  affected,  and  before  long  there  may  be  a  failure  to  recog- 
nise things  or  ability  to  give  a  name  to  them.  Ideational 
inertia  is  often  a  prominent  symptom  ;  the  patient  becomes 
disorientated  for  time  and  place,  even  mistaking  his  residence. 
As  time  goes  on  the  failure  of  the  memory  becomes  more  and 
more  marked.  This  amnesia  is  commonly  a  prominent  symp- 
tom. It  may  lead  to  serious  breaches  of  the  social  and  moral 
laws.  Loss  of  memory  may  entirely  prevent  a  person  from 
earning  his  livelihood,  or  it  may  interfere  with  his  ability  to  find 
his  way  about  the  streets  or  even  his  own  home.  On  these 
grounds  amnesia  alone  may  necessitate  the  removal  of  a 
patient  to  a  mental  hospital.  His  loss  of  memory  and  liability 
to  forget  where  he  placed  things  may  lead  to  his  making  accusa- 
tions against  others  that  they  have  robbed  him. 

After  a  time  with  failure  of  recent  memory  there  may  be 
exaltation  of  the  remote  and  more  organised  memory.  Events 
long  past  may  be  recalled  with  such  vividness  that  they  seem 
to  have  happened  but  yesterday.  Family  secrets,  which  have 
long  been  kept  and  almost  forgotten,  are  related  to  the  com- 
parative stranger  as  matter  of  ordinary  interest.  Nothing 
is  sacred  to  the  senile  dement ;  he  loses  all  sense  of  propor- 
tion, aU  power  of  control.  There  may  be  in  some  cases  pro- 
found confusion  of  mind  ;  apraxia,  sensory  and  motor,  occurs 
in  this  disease  more  commonly  than  in  any  other  forms  of 
mental  disorder.  The  emotional  aspect  is  one  of  instability 
and  alternates  between  phases  of  weeping  and  laughing.  Irrita- 
bility may  be  very  marked.  Eestlessness  is  usually  very 
noticeable  and  may  be  accompanied  by  outbursts  of  excite- 
ment.    The  patient  may  wander  about  aimlessly,  mistaking 


SENILE  INSANITY  191 

identity,  making  false  accusations,  and  behaving  generally  in  an 
insane  manner.  A  man  in  this  condition  may  make  mifounded 
charges  of  mifaithfulness  against  his  wife,  and  such  a  belief  may 
lead  to  his  altering  his  will  or  mfluence  him  when  making  it. 

As  dissolution  progresses,  the  habits  may  become  degenerate 
and  sooner  or  later  the  control  over  the  bladder  and  rectum 
is  lost.  The  sexual  instinct  not  infrequently  becomes  dis- 
ordered, and  this  may  be  one  of  the  earHest  symptoms  to 
attract  attention  ;  this  subject  has  already  been  fully  discussed 
in  dealing  with  other  types  of  senile  mental  disorder,  and  what 
has  been  written  applies  with  even  greater  force  in  these 
cases  as  the  symptoms  may  occur  quite  early.  Delusions 
and  false  beliefs  of  almost  every  kind  may  haunt  him  ;  often 
they  are  fleeting,  though  by  no  means  always  so.  Hallucina- 
tions, more  especially  visual  and  auditory,  are  common  and 
may  be  the  cause  of  much  distress  to  the  patient.  Sleep 
varies  ;  usually  there  is  insomnia  at  night  with  great  restless- 
ness, but  during  the  day  a  tendency  to  drowsiness. 

Physical  Symptoms. — With  old  age,  whether  it  occurs 
prematurely  or  not,  there  is  a  general  failure  of  all  physical 
activity.  Every,  system  shows  the  mark  of  time  upon  it. 
Functions  which  formerly  were  wont  to  be  performed  uncon- 
sciously and  with  ease  are  now  imperfectly  or  even  painfully 
effected.  In  the  ordinary  functional  psychoses  the  bodily 
changes  are  not  so  marked  and  serious  as  in  the  organic  forms 
of  this  disorder.  In  the  former,  the  changes  are  largely  those 
found  in  other  cases  of  excitement  or  depression  ;  but,  in 
addition,  there  wiU  be  great  decrepitude  and  other  symptoms  of 
increasing  age.  In  arteriopathic  dementia  the  physical  changes 
are,  as  a  rule,  more  profomid. 

The  gastro-intestmal  system. — There  may  be  anorexia  :  the 
tongue  is  furred,  with  slight  tremor  ;  obstinate  constipation 
is  common,  with  a  tendency  to  diarrhoea  at  times. 

The  circulatory  system  may  show  signs  of  marked  degenera- 
tion. The  heart  may  be  dilated  or  exhibit  other  symptoms 
of  disease  ;  the  arterial  walls  may  be  thickened  and  show 
sclerotic  changes.  The  pulse  may  be  slow,  frequent,  or  u-regular. 
An  intermittent  pulse  is  not  micommon,  but  intermittency 
is  not  so  important  a  symptom  as  irregularity. 

The  respiratory  system  may  become  seriously  affected  during 


192  PSYCHOLOGICAL  MEDICINE 

an  attack  of  senile  insanity ;  hypostatic  pneumonia  is  a 
common  cause  of  death. 

The  genito-urinary  system  is  also  affected,  retention  or 
incontinence  being  among  the  constant  symptoms.  The 
catheter  has  often  to  be  employed,  and  even  when  used  with  the 
greatest  care  it  may  lead  to  vesical  and  other  troubles.  The 
urine  in  the  arteriosclerotic  cases  is  usually  very  abundant  and 
of  low  specific  gravity.  Prostatic  enlargement  is  also  common, 
and,  according  to  some  authorities,  plays  an  important  part  in 
setting  up  sexual  disturbances. 

The  nervous  system  does  not  escape,  and  in  addition  to 
disorders  of  the  special  senses,  such  as  illusions  and  hallucina- 
tions already  alluded  to,  many  other  symptoms  may  be 
encountered.  Vertigo  and  singing  in  the  ears  are  constantly 
complained  of,  and  there  may  be  slight  apoplectiform  seizures, 
which  in  rare  cases  are  followed  by  paralysis.  Cutaneous 
sensation  may  be  disordered,  and  there  may  be  pupillary 
changes  with  defect  of  the  various  eye  reflexes. 

The  7nuscular  system  shows  failure  in  many  directions. 
Fine  co-ordinate  movements  are  no  longer  possible.  The 
handwriting  is  especially  affected,  for,  although  it  keeps  its 
.former  characteristics,  it  becomes  shaky  and  shows  tremor 
and  loss  of  power.  There  is  tremulousness  of  all  muscles  ;  the 
gait  is  unsteady,  and  ultimately  the  patient  may  become  bed- 
ridden. The  speech  also  shows  failure  of  power  over  lips  and 
tongue.  The  body  weight  falls,  and  the  skin,  nails,  hair,  etc., 
all  show  nutritional  changes.  The  body  temperature  is  about 
normal,  and  any  f everishness  usually  indicates  the  onset  of 
some  intercurrent  malady.  Sleep  is  uncertain  and  may  be 
either  excessive  or  deficient. 

Course. — With  the  functional  psychoses  the  course  is  similar 
to  that  of  states  of  depression  or  excitement  observed  at  other 
epochs  of  life.  The  mental  disturbances  may  not  be  severe, 
and  if  the  bodily  health  does  not  suffer  to  any  great  extent, 
the  attack  may  be  of  comparatively  short  duration.  With 
arteriopathic  dementia  it  is  different,  progress  then  being  one 
of  steady  deterioration  ;  death  may  ensue  at  any  time  from 
some  intercurrent  disease. 

Diagnosis. — There  should  be  no  difficulty  in  distinguishing 
between  the  curable  forms  of  insanity  occurring  in  old  persons 


SENILE  INSANITY  193 

and  true  arteriopathic  dementia.  In  the  latter  the  profound 
loss  of  memory,  imperception,  disorientation,  etc.,  should  soon 
make  the  diagnosis  clear.  The  greater  difficulty  may  arise 
in  distinguishing  some  cases  of  arteriopathic  dementia  of 
syphilitic  origin  from  general  paralysis  of  the  insane.  Here 
again  disturbances  of  memory,  perception  and  orientation 
are  usually  more  profound  in  the  patient  with  arteriosclerotic 
disease.  In  the  slowly  progressive  forms,  it  is  often  very 
difficult  to  say  when  the  line  of  insanity  has  been  crossed, 
and  to  distinguish  physiological  dotage  from  actual  disorder. 
In  these  cases  the  diagnosis  must  largely  depend  upon  the 
conduct  and  the  presence  of  delusions  or  hallucinations  which 
influence  the  actions  of  the  patient. 

Prognosis. — The  prognosis  is  never  very  favourable,  but 
many  senile  patients  suffering  from  mania  or  melancholia 
recover  to  a  very  marked  degree.  It  is  important  to  remember 
that,  even  in  pre-senile  insanities  as  well  in  those  occurring 
during  the  years  of  decadence,  an  attack  of  insanity  usually 
incapacitates  a  man  from  further  work,  though  he  may  suffi- 
ciently recover  to  be  able  to  perform  social  duties  and  live 
quietly  at  home.  Some  senile  patients  remain  very  comfort- 
able and  happy  in  an  asylum,  but  relapse  at  once  when  dis- 
charged. The  even  life  of  an  institution  suits  them,  but  the 
slightest  worry  or  trouble  causes  them  again  to  break  down. 
These  persons  can  often  be  allowed  out  on  parole  with  their 
friends,  but  they  must  have  the  protection  which  an  institution 
affords  them.  With  severe  cases,  where  there  is  intense 
restlessness  and  insomnia,  the  outlook  is  very  bad.  In  arterio- 
pathic dementia  the  prognosis  is  bad,  the  disease  may  pro- 
gress either  rapidly  or  slowly,  and  in  the  syphilitic  cases  may 
be  arrested  for  a  time  under  treatment. 

Pathology  and  Morbid  Anatomy. — We  are  still  in  the  dark 
as  to  why  atrophy  and  degeneration  take  place  in  old  age  ; 
that  everything  grows  old  is  certain,  but  why  this  is  the  case 
is  a  problem  for  futurity  to  solve.  Some  authorities  believe 
that  the  change  is  due  to  an  autotoxic  condition  and  state 
that  senile  involution  is  not  due  to  natm'al  failure  of  vital 
energy,  but  that  it  is  a  degeneration  of  toxic  origin.  Ford 
Eobertson  i  strongly  supports  this  theory,  and  goes  so  far  as 

1  Pathology  of  Mental  Disease. 

13 


194  PSYCHOLOGICAL  MEDICINE 

to  say  :  '  In  typical  cases  of  senile  insanity  the  evidence  in 
support  of  the  essentially  autotoxic  nature  of  the  pathological 
changes  is,  to  my  mind,  absolutely  conclusive.  Indeed,  I 
would  regard  senile  insanity  as  the  best  example  that  we  have 
of  mental  derangement  determined  by  auto-intoxication.  The 
kidneys  are  cirrhotic  ;  the  liver  is  atrophied,  or  shows  some 
other  forms  of  chronic  morbid  change  ;  the  lungs  are  often 
emphysematous,  or  present  evidence  of  chronic  congestion ; 
there  is  frequently  chronic  bronchitis  ;  the  stomach  is  com- 
monly dilated,  and  there  are  generally  signs  of  imperfect 
intestinal  action.  All  of  these  morbid  conditions  of  the 
internal  organs  imply  incomplete  and  perverted  metabolism, 
and  consequent  auto-intoxication.' 

Ford  Eobertson  contends  '  that  normal  senile  involution 
is  associated  with  auto-intoxication,  and  that  senile  insanity 
essentially  represents  a  more  intense,  and  in  some  respects 
irregular,  form  of  the  same  condition,  although,  no  doubt, 
additional  factors  are  often  added.'  This  theory  of  auto- 
intoxication is  suggestive  and  full  of  interest,  and  is  supported 
by  a  large  body  of  evidence.  It  is  a  theory  which  might 
explain  why  one  man  grows  old  before  another,  and  why  some 
diseases  tend  to  decadence  more  markedly  than  others.  With 
aU  this,  there  seems  to  be  something  lacking,  and  it  is  not 
wholly  convincing.  Atrophy  and  decay  seem  to  be  too  regular 
in  their  onset  to  be  explained  by  such  a  theory,  for  with  autumn 
all  vegetation  dies  together.  Further,  in  the  animal  world 
senility  appears  at  different  ages  for  different  creatures,  and 
yet  each  reaches  its  allotted  span  within  narrow  limits.  One 
would  rather  expect  to  find  that  decay  and  autotoxic  changes 
are  the  result  of,  or  have  been  permitted  to  take  place  by, 
some  subtle  alteration  in  the  tissues,  and  that  they  are  merely 
symptoms  of  some  third  and  primary  cause. 

The  following  are  the  most  noticeable  microscopic  changes. 
The  brain  is  atrophied  and  lighter  than  normal.  The  skull  may 
be  thickened,  and  the  dura  is  commonly  found  to  be  adherent 
to  the  calvarium.  The  Pacchionian  bodies  are  increased  in 
size.  The  pia-arachnoid  is  also  thickened  and  may  contain 
some  milky  opacities  ;  it  is  scarcely  ever  found  to  be  adherent 
to  the  convolutions,  and,  as  a  rule,  strips  readily.  Pachy- 
meningitis interna   haemorrhagica   has    been    found   in   some 


SENILE  INSANITY  195 

cases.  The  convolutions  are  atrophied  and  shrunken,  and 
the  sulci  are  wide.  There  is  a  great  increase  of  the  cerebro- 
spinal fluid  ;  the  ventricles  are  dilated,  and  the  ependyma  is 
thickened  but  rarely  granular.  Small  localised  softenings 
may  be  seen  especially  in  the  Eolandic  areas  and  the  basal 
ganglia.  There  is  extensive  thickening  of  the  blood-vessels, 
especially  in  the  cerebral  arteries.  In  syphilitic  cases  the 
thickening  is  of  the  inner  coat,  whereas  in  the  arteriosclerotic 
cases  it  is  in  the  middle  coat.  Miliary  aneurisms  may  also 
be  observed.  Microscopically  the  nerve  cells  are  found  to  be 
atrophied  and  degenerate ;  chromatolysis  and  achromatolysis 
are  to  be  observed.  The  neuroglia  throughout  the  cortex  is 
increased,  and  some  of  the  cells  show  pigmentary  degeneration. 
Treatment. — The  treatment  of  any  given  case  depends  on 
the  type  of  the  insanity.  The  reader  is  referred  to  the  various 
chapters  on  the  special  mental  disorders  and  to  the  one  on 
Treatment  in  general. 


196  PSYCHOLOGICAL  MEDICINE 


CHAPTEE  XIII 

INTOXICATION  PSYCHOSES  :  ALCOHOLISM  AND  KORSAKOW'S 
DISEASE,   MORPHINISM,   COCAINISM,   PLUMBISM 

Alcoholism 

The  relationship  of  alcohol  to  insanity  is  very  close  indeed. 
As  an  individual  cause  of  mental  disorder,  alcohol  probably 
stands  pre-eminent ;  for  it  not  only  affects  the  individual, 
but  if  he  has  children  it  engenders  in  his  offspring  a  tendency 
to  intemperance,  epilepsy,  idiocy,  or  insanity.  Alcohol  may 
act  with  injurious  effect  on  any  organ  of  the  body.  In  acute 
intoxication  it  is  the  highest  parts  of  the  nervous  system  that 
suffer  most  severely,  but  the  other  systems  of  the  body  are 
directly  or  indirectly  affected.  One  person  will  tolerate 
alcohol  to  a  greater  extent  than  another.  This  is  well  shown 
by  the  effect  of  alcohol  on  different  races.  Most  primitive 
peoples  are  extremely  intolerant  of  the  drug,  the  effects  of 
which  in  time  will  even  threaten  the  continued  existence 
of  such  races.  Nations  such  as  the  English  can  take  alcohol 
with  greater  impunity,  at  any  rate  so  far  as  the  immediate 
effects  are  concerned. 

The  nervous  system  suffers  most  from  the  effects  of  alcohol, 
yet  some  persons  may  drink  heavily  for  years  without  showing 
any  signs  of  marked  mental  degeneration,  though  they  may 
suffer  from  gastritis  or  cirrhosis  of  the  Uver.  The  fate  of 
an  individual  is  probably  largely  decided  by  his  inherited 
tendencies.  Alcohol  attacks  the  weakest  system  of  the  organ- 
ism. If  the  nervous  system  is  unstable,  it  will  be  early  affected, 
and  it  must  be  remembered  that  this  instability  may  be  either 
inherited  or  acquired.  Instability  originating  from  sunstroke 
or  head-injury  will,  under  the  influence  of  alcohol,  produce 
more  pernicious  results  than  even  congenital  defects.  Alcohol 
not  only  lowers  the  powers  of  resistance  of  the  organism  to 


ALCOHOLISM  197 

certain  diseases,  but  it  seriously  complicates  almost  every 
malady.  To  sum  up  :  alcoholism  is  so  far-reaching  in  its 
results  that  in  the  individual  we  find  a  progressive  tendency 
to  mental  and  bodily  deterioration  and  a  lowered  resistance 
to  disease  ;  in  the  offspring,  a  proneness  to  idiocy,  epilepsy, 
and  criminality  ;  and  in  the  race,  a  higher  disease  rate,  a  higher 
mortality  rate,  and  a  lowered  birth  rate. 

etiology. — A  neurotic  inheritance  is  by  far  the  most  im- 
portant factor.  The  instability  may  show  itself  early  in  life  by 
convulsions,  night  terrors,  precocious  evolution,  or  physical 
and  mental  stigmata  of  degeneracy.  In  some  persons  alcoholic 
habits  are  merely  the  result  of  a  degenerate  type  of  mind,  the 
moral  sense  being  defective  ;  to  this  class  the  common  drunkard 
belongs.  Another  class,  which  includes  the  dipsomaniac,  may 
drink  intermittently  from  a  periodic  impulsive  desire. 

Habit  is  an  important  element  in  the  causation  of  alcohol- 
ism. A  large  number  of  persons  first  drink  alcohol  either 
from  social  or  business  reasons  ;  from  being  light  they  become 
moderate  drinkers  ;  ultimately  they  may  find  that  they  have 
created  a  habit  from  which  they  cannot  free  themselves. 
Such  persons  may  have  had  no  inherited  tendency  to  alcoholism, 
but  have  acquired  it  in  their  lifetime.  There  are  epochs 
in  life  in  which  the  habit  is  more  easily  acquired  than  at 
others  ;  in  women,  from  forty  to  fifty  years  of  age  appears 
to  be  a  dangerous  period.  Medical  men  are  not  always  free 
from  blame  for  originating  an  alcoholic  habit.  A  glass  of  wine 
or  spirit  is  recommended  for  all  kinds  of  indefinite  neuralgia 
and  discomfort.  Temporary  relief  may  be  obtained,  and  the 
dose  is  constantly  repeated  until  it  becomes  almost  a  necessary 
food.  Again,  with  fatigue  and  stress  of  work  a  man  may  fly 
to  alcohol  to  stimulate  his  flagging  brain  and  find  that  it 
supplies  the  energy  he  needs.  Instead  of  restoring  his 
forces  by  the  rest  and  nourishment  which  nature  requires,  he 
creates  by  the  use  of  alcohol  a  fictitious  activity  and  the 
worn-out  nervous  system  has  to  work  on.  The  day  of  reckon- 
ing must  inevitably  come  ;  there  is  a  mental  break-down, 
probably  complicated  by  the  alcohol  which  has  been  taken 
to  stave  it  off. 

Alcohol  which  contains  various  impurities  has  undoubtedly 
a  very  deleterious  effect  on  the  economy  of  the  organism. 


198  PSYCHOLOGICAL  MEDICINE 

For  this  reason  it  is  incumbent  upon  governments  and  ad- 
ministrations to  protect  the  public  from  all  kinds  of  adulterated 
wines  and  spirits.  A  word  of  caution  may  be  added  to  this 
discussion  upon  alcohol  as  a  cause  of  insanity.  No  doubt  it 
is  a  very  potent  cause,  but  it  may  also  be  an  early  symptom 
of  mental  disease.  The  physician  must  be  careful  to  dis- 
tinguish between  cause  and  effect.  Further,  defective  control 
may  be  the  scar  left  by  a  former  attack  of  insanity,  and  it 
may  show  itself  in  a  tendency  to  drink.  In  conclusion,  the 
reader  need  hardly  be  reminded  that  constant  '  nipping  '  is, 
as  a  rule,  far  more  damaging  to  the  nervous  system  than 
isolated  bouts  of  drinking. 

Varieties. — The  forms  of  alcoholism  to  which  we  shall 
refer  include  both  acute  and  chronic  intoxication.  In  the 
former  the  mental  disorder  is  largely  due  to  the  direct  toxic 
influence  of  the  poison  on  the  brain,  while  in  the  latter  it  is 
often  the  result  of  structural  alteration  in  the  cerebral  blood- 
vessels and  nervous  elements.  The  following  conditions 
will  now  be  considered  in  detail  :  (1)  Acute  i7itoxication  or 
drunkenness ;  (2)  delirium  tremens ;  (3)  mania-a-'potu ;  (4) 
chronic  alcoholism  ;  (5)  chronic  alcoholic  insanity  ;  (6)  dipso- 
mania ;   (7)   Korsakow's  disease  (polyneuritic  psychosis). 

Acute  Intoxication. — Mental  Symptoms. — Acute  intoxication 
or  drunkenness  is  of  interest  to  the  mental  physician,  as  in 
some  predisposed  persons  a  temporary  delirium  may  pass 
on  into  more  permanent  insanity.  A  state  of  drunkenness 
is  usually  caused  by  a  large  quantity  of  alcohol  being  taken 
within  a  short  space  of  time,  but  in  the  case  of  epilep- 
tics, or  of  those  who  have  suffered  from  sunstroke  or  head- 
injury,  small  quantities  of  alcohol  may  suffice  to  produce 
intoxication.  Alcohol  exaggerates  the  normal  temperament. 
The  weak-minded  person  becomes,  under  its  influence,  foolish  ; 
the  morose  man  weeps  ;  the  excitable  man  becomes  merry  and 
exalted.  All  the  types  of  mental  disorder  associated  with 
acute  intoxication  need  not  be  described  ;  they  vary  from 
stupor  and  mental  confusion  to  wild  excitement.  The  vast 
majority  of  intoxicated  individuals  recover  within  a  few  hours, 
but  occasionally  cases  occur  in  which  the  mental  disorder 
persists  for  days  or  weeks.  Epileptic  convulsions  may  be 
observed  in  a  small  percentage  of  these  patients. 


ALCOHOLISM  199 

Physical  Symptoms. — The  physical  disorders  of  drunken- 
ness are,  like  the  mental,  very  varied.  One  person  will 
suffer  from  sickness  and  gastritis ;  another  from  severe 
motor  inco-ordination  and  headache. 

Delirium  Tremens. — Mental  Symptoms. — Delirium  tremens 
is  not  often  met  with  in  asylums,  as  the  attack  is  usually  of 
short  duration.  There  are,  however,  points  of  interest  in  the 
condition  to  which  attention  should  be  drawn.  It  is  often 
caused  by  taking  a  large  quantity  of  alcohol  within  a  com- 
paratively short  space  of  time.  But  this  is  not  always  so — 
witness  those  cases  in  which  no  alcohol  has  been  taken  for 
weeks  ;  again,  delirium  tremens  appears  after  an  injury  or 
shock,  or  in  connection  with  some  illness,  such  as  pneumonia. 
.  Sudden  enforced  abstinence  does  not  in  itself  induce  an  attack 
of  delirium  tremens,  as  the  evidence  of  prison  officials  clearly 
decides.  Stoddart  suggests  that  as  the  introduction  of  any 
poison  into  the  system  stimulates  the  tissues  to  throw  out 
defensive  substances  of  various  kinds,  it  seems  likely  that, 
in  the  case  of  chronic  alcoholism,  these  would-be  defensive 
substances,  being  produced  in  excess,  may  be  partly  the  cause 
of  delirium  tremens.  During  the  attack  the  patient  is  un- 
doubtedly of  unsound  mind.  The  onset  is  not  always  so 
sudden  as  is  often  supposed  ;  it  is  usually  preceded  by  a  period 
of  nervo-muscular  excitability.  The  sufferer  is  impulsive,  flies 
into  a  sudden  passion  without  adequate  cause,  and  becomes 
timid,  suspicious,  restless,  and  gloomy.  The  approach  of 
night  brings  an  increase  in  the  force  of  his  fears,  suspicions, 
restlessness,  and  sense  of  gloom.  He  does  not  sleep  and 
misinterprets  every  sound.  As  time  goes  on,  hallucinations, 
generally  visual  in  character,  appear  at  night.  Animals  and 
insects  crawl  about  his  bed,  vampires  and  imps  hover  around 
him.  He  hears  the  noise  of  angry  crowds  shouting  or  singing 
outside,  and  is  terrified,  for  he  knows  they  '  seek  his  life.'  Less 
frequently  the  other  senses  are  disordered  ;  he  believes  that 
poison  is  placed  in  his  food,  or  smells  the  sulphurous  gases  that 
are  driven  into  his  room.  As  the  case  progresses,  the  halluci- 
nations appear  by  day  as  well  as  by  night.  Delusions  develop  in 
explanation  of  the  various  sensory  phenomena.  The  hallucina- 
tions are  ever  changing  and  are  usually  terrifying  to  the 
patient. 


200  PSYCHOLOGICAL  MEDICINE 

Patients  with  delirium  tremens  frequently  mistake  identity  ; 
the  memory  is  good  for  remote  events,  but  is  bad  for  the 
more  recent.  Disorientation  is  common  ;  they  mistake  their 
bedroom  for  a  ship's  cabin,  or  the  hospital  for  a  prison.  Im- 
perception  is  also  to  be  noted  in  the  more  extreme  cases. 
Attention  can  usually  be  obtained  for  a  few  moments.  Eest- 
lessness  marks  their  actions,  and  they  constantly  occupy  them- 
selves with  their  various  hallucinations  and  delusions,  and  they 
tend  to  be  impulsive.  Some  of  these  patients  are  very  suicidal, 
preferring  death  to  continued  persecution. 

Physical  Symptoms. — The  gastro-mtestinal  system  is  dis- 
ordered, the  tongue  is  furred  and  tremulous.  There  is  anorexia 
and  refusal  of  food ;  the  bowels  are  commonly  constipated. 
The  pulse  is  low-tensioned  and  frequent.  Kesphation  is 
slow.  The  temperature  is  usually  normal,  and  rarely  exceeds 
100°  F,  The  skin  is  moist,  and  the  patient  often  perspires 
freely.  There  is  tremor  of  most  of  the  muscles,  and  speech 
is  affected.  Epileptic  convulsions  may  occm'.  The  patient 
suffers  from  intense  sleeplessness,  the  presence  of  which 
symptom  may  make  the  prognosis  grave. 

Course. — In  the  large  majority  of  cases  the  course  of 
delirium  tremens  is  towards  recovery.  Hallucinations  begin 
to  disappear  by  day,  only  recm-ring  by  night  ;  later  they 
vanish  altogether.  Slowly  the  consciousness  clears,  and  the 
mental  equiHbrium  becomes  re-established.  In  a  small  per- 
centage of  cases  the  result  is  not  so  good.  If  there  is  a 
large  amount  of  albumen  in  the  urine,  or  if  there  is  suppression 
of  urine,  the  prognosis  is  grave.  To  summarise  briefly,  the 
risks  of  delirium  tremens  are  as  follows  :  (1)  That  the  patient 
may  pass  into  a  condition  of  stupor  and  coma  and  ultimately 
die.  (2)  That  the  hallucinations  may  persist  after  the  other 
symptoms  have  subsided.  (3)  That  delusions  of  persecution, 
poisoning,  etc.,  may  persist.  (4)  That,  after  the  attack,  the 
finer  attributes  of  the  patient's  character  may  become  dulled, 
and  lazy  and  immoral  habits  develop.  (5)  That  from  the 
temporary  dehrium  the  patient  may  pass  into  a  state  of 
ordhiary  acute  mania. 

Diagnosis. — Delirium  tremens  must  be  distinguished  in 
diagnosis  from  acute  delirious  mania.  In  the  latter  the  tem- 
perature is  raised,  and  the  hallucmations,  though  abundant, 


ALCOHOLISM  201 

are  not  terrifying  ;  in  delirium  tremens,  the  somatic  symptoms 
and  the  historj^  form  the  best  guide. 

Treatment. — Place  patient  in  a  darkened  room  and  always 
have  two  nurses  in  attendance.  It  is  important  to  give  plenty 
of  nourishment  and,  in  many  cases,  it  is  necessary  to  give  some 
alcohol  in  the  form  of  champagne  during  the  early  stages  of. 
the  ilhiess,  especially  in  enfeebled  persons.  This  may  prevent 
the  sudden  collapse  which  may  occur  on  the  third  or  fourth  day. 
Hypnotics  should  be  administered,  but  at  first  frequently  are 
of  httle  help.  Amylene  hydrate  one  and  a  half  to  two  drachms 
alternately  with  thirty  grains  of  sulphonal  often  answers  well. 
Also  hyoscine  y^  grain  twice  a  day  may  be  given. 

Mania-a-potu. — <  Mania-a-j)oiu  is  another  form  of  acute 
iilcoholism,  its  chief  interest  lying  in  its  medico-legal  aspect. 
These  patients  suffer  from  a  very  acute  form  of  excitement, 
but  usually  make  rapid  improvement  when  placed  under 
proper  treatment.  The  condition  differs  from  that  of  delirium 
tremens  in  that  there  is  not  the  same  degree  of  physical  pros- 
tration. Sufferers  from  delirium  tremens  look  ill,  but  those 
with  mania-a-jpotu  commonly  appear  in  good  health.  The 
latter  usually  have  an  insane  inheritance,  and  very  little 
drink  will  produce  the  condition. 

Mental  Symptoms. — The  intense  excitement  in  many  ways 
resembles  epileptic  furor.  The  maniacal  attack  is  sudden  in 
its  onset  and  extreme  in  its  violence  ;  homicidal  assaults  are 
by  no  means  uncommon.  The  sufferer  is  boastful  and  ego- 
tistical and  may  be  extremely  exalted  and  extravagant.  He 
spends  money  lavishly  and  may  write  cheques  far  exceeding 
the  balance  at  his  bank.  He  is  noisy  and  threatening  in  his 
conversation  and  quarrels  with  his  best  friends.  Hallucina- 
tions are  rare.  If  a  patient  of  this  class  is  certified  and 
placed  under  care,  he  often  improve es  rapidly,  and  when  this 
takes  place  the  friends  and  the  patient  himself  will  frequently 
upbraid  the  medical  attendant  for  having  needlessly  placed 
him  in  an  asylum.  On  the  other  hand,  if  allowed  to  retain 
his  liberty,  the  patient  may  injure  others  in  his  violence  and 
may  compromise  himself  and  his  family  financially.  A  medical 
man  ought  always  to  call  in  a  colleague  to  discuss  the 
treatment  to  be  adopted,  and  then  fully  explain  to  the 
friends   the  probable  course   the  illness  will   take  ;    he  may 


202  PSYCHOLOGICAL  MEDICINE 

advise  them,  but  it  will  be  wiser  to  leave  to  them  the 
ultimate  decision  as  to  what  shall  be  done.  Treatment  will 
be  discussed  later. 

Physical  Symptoms. — -The  general  health  is  usually  good. 
The  tongue  may  be  furred,  and  there  is  often  analgesia.  In- 
somnia is  a  constant  and  trying  symptom  and  it  is  frequently 
necessary  to  procure  sleep  by  artificial  means. 

Course. — When  once  sleep  has  been  obtained  and  the 
patient  is  under  proper  care,  the  course  is  generally  towards 
recovery  ;  and  in  many  cases  this  takes  place  in  about  a 
month  or  six  weeks,  and  occasionally  within  a  few  days. 

Diagnosis. — The  diagnosis  is,  as  a  rule,  by  no  means  diffi- 
cult when  the  history  is  clear.  The  condition  must  be  dis- 
tinguished from  epileptic  excitement  and  other  forms  of  acute 
mania.  The  physician  must  not  forget  to  look  for  physical 
signs  of  general  paralysis,  for  this  disease  may  begin  with 
sudden  excitement. 

Chronic  Alcoholism. — Chronic  alcoholism  is  brought  about 
by  the  steady  ingestion  of  spirits  over  a  period  of  months  or 
years.  The  alcohol  is  usually  taken  in  small  quantities  but 
frequently  repeated.  In  some  cases  the  somatic  disturbances 
are  the  most  prominent  characteristics  of  the  condition  ;  others 
show  a  gradual  and  progressive  mental  deterioration.  For  a 
long  time  there  may  be  nothing  more  than  an  increasing 
apathy  and  confusion  of  mind.  Uncertainty  of  memory  and 
unreliability  in  work  may  be  observed.  During  this  time 
sensory  and  motor  disturbances  may  appear,  varying  in 
severity  in  different  cases.  The  whole  condition  is  one  of 
stead}  deterioration.  This  general  failure,  whether  it  be 
mental,  motor,  or  sensory,  follows  the  law  of  dissolution 
of  the  nervous  system  ;  i.e.  the  latest  acquired,  and  therefore 
the  least  organised  attributes  go  first,  and  in  the  sensory  or 
motor  systems  the  derangements  first  aj)pear  at  the  periphery 
and  extend  towards  the  centre. 

Mental  Symptoms. — The  power  of  attention  steadily  fails, 
and  there  is  a  progressive  weakening  of  the  intellectual 
faculties.  The  memory  becomes  markedly  affected,  and  there 
is  inability  to  store  fresh  impressions.  The  amnesia  becomes 
more  and  more  serious,  until  finally  the  patient  may  not  only 
be  unable  to  do  his  daily  work,  but  may  become  incapable  of 


ALCOHOLISM  203 

looking  after  himself  and  his  affairs.  With  this  forgetful- 
ness  there  is  often  great  irritability,  and  the  patient  becomes 
suspicious  of  the  intentions  of  those  with  whom  he  is  asso- 
ciated. The  loss  of  the  moral  sense  is  very  noticeable  and 
may  be  an  important  symptom.  The  finer  attributes  of  the 
character  disappear  and  give  place  to  untruthfulness  and 
general  untrust worthiness.  The  language  is  often  obscene,  and 
all  sense  of  decency  may  be  lost.  The  chronic  alcoholic  may 
thus  place  himself  within  the  reach  of  the  law  by  an  offence 
against  the  social  and  moral  codes.  There  may  be  outbursts 
of  loss  of  control,  with  destructiveness.  An  overbearing 
and  offensive  manner  towards  their  relatives  often  marks 
the  attitude  of  these  patients,  which  brings  discomfort  and 
■misery  to  their  homes. 

Physical  Symptoms. — These  vary  greatly  in  different  indi- 
viduals. Gastritis  and  anorexia  are  common.  Speech  is 
blurred  and  defective.  The  gait  is  uncertain  owing  to  general 
loss  of  tone  in  the  muscles.  There  is  a  fine  tremor  of  the 
hand  and  fingers,  which  is  first  noticeable  in  the  morning 
and  subsequently  becomes  manifest  all  day.  The  oscillations 
are  regular  and  rapid  and  are  exaggerated  by  voluntary 
movements.  The  tremor  of  the  alcoholic  has  the  peculiarity 
that  it  decreases  under  the  influence  of  drink  and  is  most 
marked  in  the  early  morning,  when  the  immediate  effect  of  the 
poison  ha&  passed  off.  Ingestion  of  more  alcohol  for  the  time 
re-establishes  the  equilibrium,  and  the  tremor  disappears ; 
this  is  a  characteristic  of  all  poisons.  It  is  for  this  reason  that 
the  chronic  drinker  says  that  he  is  incapable  of  work  until  he 
has  had  his  morning  glass  of  spirit. 

There  is  inco-ordination  of  movements,  the  finer  adjust- 
ments, such  as  are  necessary  for  handwriting,  etc.,  being  most 
affected.  Vertigo  is  a  common  symptom.  Peripheral  neuritis 
may  be  observed  in  these  cases,  more  especially  in  females.  The 
knee-jerks  are  exaggerated,  diminished,  or  lost ;  there  may  be 
wasting  of  the  extensor  muscles  of  the  leg,  producing  foot-drop. 
Convulsions  may  be  due  to  organic  disease,  such  as  atheroma, 
softenings,  haemorrhages,  though  at  other  times  they  seem 
to  be  due  to  some  temporary  disturbance.  The  motor  dis- 
turbances usually  appear  before  the  sensory.  The  latter,  Uke 
disorders  of  movement,  begin  in  the  extremities  of  the  limbs 


204  _  PSYCHOLOGICAL  MEDICINE 

and  are  often  symmetrical.  These  sensory  disturbances  may 
take  the  form  of  exaggerations,  diminutions,  or  perversions 
of  general  and  special  sensibility.  Analgesia  is  common,  or  the 
patient  may  have  peculiar  sensations  about  the  skin,  such  as 
tinghng  or  pricking.  Hallucinations  and  illusions  may  begin 
to  develop  ;  at  fii'st  they  are  indefinite,  but  as  time  passes 
they  frequently  become  more  organised.  There  is  usually 
insomnia,  which  tends  to  increase  the  mental  disturbances 
already  alluded  to. 

Course. — The  course  is  usually  a  progressive  one,  and  the 
rapidity  with  which  mental  deterioration  takes  place  depends 
on  the  quantity  of  alcohol  imbibed.  Early  and  energetic 
treatment  may  be  successful  in  a  certain  percentage  of  cases. 
Some  persons  become  more  and  more  weak-minded  or  suc- 
cumb to  some  intercm-rent  malady  ;  others  develop  definite 
chronic  delusional  insanity. 

Diagnosis. — The  diagnosis  of  chronic  alcoholism  is,  as  a 
rule,  quite  easy,  but  definite  alcoholic  iasanity  may  be  con- 
fused with  other  forms  of  mental  disorder,  especially  with 
general  paralysis  of  the  insane. 

Chronic  Alcoholic  Insanity. — By  chronic  alcoholic  insanity 
we  mean  those  forms  of  mental  disorder  which  develop  as 
the  result  of  steady  drinking  over  an  extended  period.  The 
condition  may  be  one  of  progressive  weakening  of  the  in- 
tellectual faculties,  until  permanent  dementia  ultimately 
results.  Other  persons  develop  a  condition  of  mental  confusion 
or  stupor  ;  others,  again,  may  exhibit  an  acute  or  chronic 
delusional  mental  disorder.  Finally,  there  are  those  who 
manifest  an  insanity  which  closely  resembles  general  para- 
lysis of  the  insane,  and,  for  want  of  a  better  term,  has 
been  called  alcoholic  fseudo-general  'paralysis,  or  alcoholic 
'pseudo-paresia. 

Mental  Symptoms. — If  the  condition  is  one  of  progressive 
dementia,  there  is  a  steady  failure  of  all  the  mental  faculties. 
The  loss  of  memory  is  very  marked  and  may  be  the  symptom 
which  finally  decides  the  necessity  of  placing  the  patient 
under  care.  As  time  passes,  there  is  an  increasing  mental 
deterioration  ;  the  patient  becomes  diity  in  his  habits  and 
loses  all  power  over  his  sphincters.  He  frequently  mistakes 
identity  and    may   have   hallucinations  of  any  sense,   most 


ALCOHOLISM  205 

commonly  of  the  auditory  and  visual.  From  time  to  time 
he  may  express  delusions,  but  with  increasing  dementia 
they  tend  to  disappear.  The  delusional  type  is  probably 
the  most  common ;  it  may  develop  somewhat  rapidly  or 
quite  slowly.  The  idea  of  self,  as  has  been  already  observed, 
is  largely  dependent  upon  sensation.  Now,  if  from  any  cause 
the  special  and  general  sensations  become  disordered,  there 
is  a  great  risk  of  the  '  thought  of  self '  becoming  altered. 
Sensory  disturbances  of  all  kinds  are  common  in  chronic 
alcoholism,  and  if  they  persist  they  may  ultimately  lead  to 
delusions.  This  is  well  seen  in  the  illusions  and  hallucinations 
which  are  so  common  in  alcoholic  insanity,  in  which  sen- 
sations are  misinterpreted  and  attributed  to  mesmerism, 
hypnotism,  electricity,  and  the  like.  Having  once  satisfied 
himself  as  to  the  cause,  the  patient  will  sooner  or  later 
fashion  ingenious  tales  as  to  who  are  his  persecutors  and 
why  and  how  they  carry  on  their  campaign  against  him. 

The  auditory  hallucinations  are,  at  first,  quite  vague  and 
indefinite,  such  as  muffled  sounds,  whistling,  and  ringing  of 
bells  ;  later  they  become  organised  into  '  voices,'  which  may 
taunt  or  give  definite  commands.  The  sounds  may  appear 
to  come  from  the  next  house  or  through  the  floors  or  ceilings. 
Patients  also  hear  the  conversations  of  persons  conspiring  to 
injure  or  kill  them.  Weird  sights  are  seen  at  first  by  night 
and  later  by  day. 

A  woman  will  tell  her  nurse  that  the  bed  is  full  of  babies, 
or  that  insects  are  crawling  all  over  her  room.  She  may 
complain  that  gases  are  being  driven  through  the  walls,  and 
that  the  room  is  full  of  sulphur.  She  hears  the  electrical 
apparatus  or  telephone  at  work.  Electrical  shocks  are  felt  ; 
many  patients  will  refuse  to  go  to  sleep,  as  they  believe  that 
as  soon  as  they  are  unconscious  their  persecutors  begin  their 
.experiments.  New  words  and  apparatus  are  invented  and 
described  by  the  patients  to  account  for  the  unaccustomed 
sensations  that  they  feel.  One  man  at  Bethlem  said  that 
there  was  a  system  of  '  euphonic  distribution  '  throughout  the 
hospital,  and  that  sound  was  carried  by  means  of  a  *  needle 
apparatus '  ;  he  further  stated  that  his  persecutors  used 
'  helio balls,'  '  orophores,'  and  '  needle  forms,'  and  that  he  felt 
needles  go  into  his  head  and  then  burst.    Another  patient 


206  PSYCHOLOGICAL  MEDICINE 

said  that  he  was  a  '  switch,'  and  that  every  telephone  message 
in  the  district  was  passed  through  him. 

The  emotional  state  of  these  patients  varies,  but  very  fre- 
quently they  are  depressed  ;  this  is  especially  the  case  with 
females.  Outbm'sts  of  excitement  may  take  place,  and  acts  of 
violence  may  be  directed  against  their  supposed  persecutors. 
Fear  may  be  a  prominent  symptom;  the  patient  may  shut 
himself  up  in  a  room  mider  the  behef  that  persons  are  seeking 
his  hfe.  Disorders  of  memory  are  very  marked.  Amnesia, 
varying  in  degree,  is  an  almost  constant  symptom.  The 
memory  fails  from  the  recent  and  least  organised  ideas  to  the 
remote  and  more  organised.  The  patient  has  no  idea  of  time, 
and  if  he  recalls  an  event  he  is  unable  to  say  whether  it 
occurred  a  day  or  a  month,  or  even  a  year  ago.  A  friend  will 
call  to  see  him  and  he  may  at  once  forget  the  visit  and  even 
write  a  letter  abusing  the  friend  on  the  score  of  neglect.  One 
may  hold  a  conversation  with  an  alcohoHc  individual  and 
then  retire,  and  upon  returning  iind  the  conversation  sub- 
stantially repeated,  as  if  the  meeting  were  for  the  first  time. 

Fm'ther,  it  is  of  interest  to  note  that  when  a  man  loses 
his  memory  he  usually  loses  his  desire  to  drink.  The  failm'e 
of  memory  is  an  important  point  to  be  considered  in  the 
event  of  a  patient  suffering  from  chronic  alcohoHc  insanity 
wishing  to  make  a  will.  In  addition  to  amnesia,  illusions 
of  memory  may  occur. 

Suspicion  is  a  prominent  symptom  in  chronic  alcohoHc 
insanity  and  may  be  associated  with  delusions  of  persecution. 
A  husband  in  this  condition  wiU  often  accuse  his  wiie  of  being 
unfaithful  to  him,  and  his  hallucinations  may  support  this 
beHef.  The  various  forms  which  the  suspicions  may  take 
need  not  be  enumerated  ;  they  are  very  numerous  and  include 
apprehensions  of  injmy  to  both  person  and  property.  On 
the  other  hand,  delusions  of  grandem'  and  ideas  of  wealth  are. 
not  infrequently  met  with  in  this  condition.  An  alcohoHc 
patient  at  Bethlem  Hospital  believes  that  he  is  an  emperor 
and  that  the  hospital  building  is  liis  palace.  He  is  continually 
hearing  explosions,  and  these  he  misconstrues  into  guns  being 
fired  by  his  sentries  who  guard  the  palace.  It  is  important 
to  note  that  grandiose  ideas  occur  in  those  forms  of  insanity 
which  are  most  Hkely  to  be  degenerative  and  end  in  dementia. 


ALCOHOLISM  207 

There  are  a  few  cases  of  delusional  insanity  associated  with 
chronic  alcoholism  in  which  perception  and  ideation  are  normal 
and  the  memory  is  good.  The  usual  physical  symptoms  found 
in  alcohohc  cases  rapidly  pass  off  and  leave  the  patient  in 
apparently  normal  bodily  health.  As  in  other  chronic  delu- 
sional states  the  disturbance  of  judgment  is  the  outstanding 
characteristic  of  the  disease.  Delusions  of  any  type  may  be 
present  and  form  the  basis  upon  which  the  patient  views  and 
regulates  his  life.  The  condition  is  usually  incurable,  but 
provided  the  delusion  is  not  one  which  is  Hkely  seriously  to 
affect  his  conduct,  the  patient  may  be  allowed  a  fair  amount 
of  liberty. 

In  conclusion,  there  are  those  cases  of  alcohoHc  insanity 
-which  closely  resemble  dementia  paralytica  or  general  paralysis 
of  the  insane.  In  these  the  mental  disorders  may  be  of  any 
kind  ;  thus  there  may  be  expansive  dehrium  with  its  delusions 
of  wealth  and  social  position ;  ideas  of  persecution,  the 
patient  beUeving  himself  to  be  the  victim  of  a  foul  conspiracy  ; 
or  there  may  be  excitement  or  depression,  or  progressive 
dementia.     Hallucinations  are  often  a  prominent  symptom. 

Physical  Symptoms. — The  physical  symptoms  closely  re- 
semble those  already  described  under  chronic  alcoholism,  but 
when  the  patient  becomes  definitely  insane  the  somatic  dis- 
turbances often  become  more  elaborated  and  pronounced.  The 
motor  disturbances  include  tremors,  twitchings,  and  cramps, 
all  of  which  may  affect  any  part  of  the  muscular  system. 
Twitching  of  the  supra-orbital  muscles  is  very  common  in 
alcohohc  patients.  Tremors  of  the  tongue  and  hps  lead  to 
defects  in  speech.  Convulsions  are  occasionally  met  with. 
The  knee-jerks  may  be  absent,  exaggerated,  or  unequal.  The 
gait  is  frequently  unsteady  and  hesitating.  If  there  be  severe 
peripheral  neuritis,  the  patient  is  usually  unable  to  walk  and 
may  lose  all  control  over  the  sphincters.  The  general  failure 
is  in  the  reverse  order  to  that  in  which  the  attributes  were 
acquired,  the  most  recent  and  finer  adjustments  disappearing 
first.  The  muscular  defects  vary  from  some  slight  inco-ordi- 
nation  or  enfeeblement  to  definite  paresis  or  even  paralysis. 

The  sensory  disturbances  are  many  and  usually  appear  at  a 
later  date  than  the  motor.  As  has  been  stated,  these  sensory 
disorders  may  take  the  form  of  exaggeration,  diminution,  or 


208  PSYCHOLOGICAL  MEDICINE 

perversion  of  general  or  special  sensibility.  Perversions  of 
taste  are  common  and  may  lead  to  delusions  of  poison ; 
similarly,  all  the  other  special  senses  may  be  affected.  The 
sensory  disorders,  whether  they  are  of  the  nature  of  hyper- 
sesthesia  or  anaesthesia,  are  usually  symmetrical  in  distribu- 
tion and  are  often  readily  affected  by  changes  of  temperature. 
The  weight  usually  falls,  and  the  various  systems  of  the  body 
are  disordered  to  a  greater  or  less  extent. 

Course. — In  a  number  of  cases  when  the  patient  has  been 
placed  under  proper  treatment  and  all  alcohol  withdrawn,  the 
progress  is  towards  recovery.  The  physical  health  usually 
improves  first  and  is  soon  followed  by  mental  restoration. 
On  the  other  hand,  even  with  marked  physical  improvement, 
the  delusions  may  become  more  and  more  organised.  Per- 
sistent hallucinations  in  a  large  majority  of  cases  probably 
indicate  chronicity.  Both  the  chronically  insane  and  the 
patients  who  are  recovering  frequently  pass  through  a  quarrel- 
some and  fault-finding  stage.  They  make  all  kinds  of  un- 
founded charges,  and  are  constantly  writing  to  various  officers 
of  State  complaining  about  matters  of  a  very  trivial  nature. 
They  treat  everyone  who  is  in  authority  over  them  with 
suspicion ;  they  magnify  small  annoyances  into  intolerable 
grievances,  and  describe  in  extravagant  language  incidents 
which  are  both  trivial  and  unimportant.  In  many  cases  the 
course  is  towards  mental  enfeeblement  and  finally  ends  in 
dementia,  with  profound  loss  of  memory.  A  small  number 
die  from  exhaustion  or  intercurrent  disease. 

Diagnosis. — The  diagnosis  largely  depends  upon  a  reliable 
history  being  obtained.  The  presence  of  hallucinations  which 
have  rapidly  developed  is  often  of  assistance  in  making  an 
accurate  diagnosis.  Further,  the  presence  of  the  characteristic 
somatic  symptoms  is  also  very  helpful.  If  there  are  physical 
signs  of  organic  disease,  the  diagnosis  from  general  paralysis 
of  the  insane  is  often  very  difficult,  as  the  history  may  not 
altogether  assist.  A  history  of  syphilis  is  a  factor  which  will 
carry  great  weight,  but  it  is  by  no  means  conclusive.  The 
differential  diagnosis  between  alcoholic  pseudo-paralysis  and 
general  paralysis  must  largely  depend  on  physical  symptoms, 
as  the  nature  of  the  mental  disorder  often  gives  but  little 
assistance.     The  following  points  should  be  considered  : 


ALCOHOLISM  209 

(1)  Pupils. — There  may  be  inequality,  reflex  iridoplegia, 
etc.,  in  both  diseases,  but  the  latter  symptom  would  certainly 
strongly  favour  general  paralysis  of  the  insane. 

(2)  Primary  optic  atropliy  would  favour  general  paralysis 
of  the  insane. 

(3)  Tremors  of  tojigue  occur  in  both,  but  an  ataxic  tremor 
of  tongue  is  more  common  in  general  paralysis  of  the  insane. 

(4)  Loss  of  expression  is  observed  in  both,  but  is  more 
common  in  general  paralysis  of  the  insane. 

(5)  Greasy  condition  of  skin  and  face  is  more  common  in 
general  paralysis  of  the  insane. 

(6)  Defects  of  articulation  occur  in  both,  but  the  general 
paralytic  slurs  his  words  more  and  is  more  hesitating  than  the 
alcoholic,  whose  speech  is  usually  thick  and  blurred. 

(7)  In  letter-writing  the  general  paralytic  is  more  inclined  to 
leave  out  letters  and  clip  off  the  endings  of  his  words  than 
the  alcoholic,  but  both  show  a  tendency  to  make  their  fine 
strokes  heavy  and  thick. 

(8)  Convulsive  seizures  occur  in  both,  but  are  more 
common  in  general  paralysis,  especially  if  the  seizure  is  of 
the  nature  of  a  temporary  aphasia  or  deafness. 

(9)  Headaches  are  more  constant  in  general  paralysis. 

(10)  Knee-jerks  are  altered  in  both  and  in  the  same 
way. 

(11)  Sensory  affections  are  much  more  common  in  alcoholic 
pseudo-paralysis  and  are  of  value  in  diagnosis. 

(12)  Hallucinations  occur  in  both,  but  vivid  visual  halluci- 
nations would  favour  an  alcoholic  condition. 

(13)  Terrified  condition  of  patient  is  more  common  in 
alcoholic  insanity. 

(14)  Voluminous  writing  favours  diagnosis  of  general 
paralysis  of  the  insane. 

(15)  Buying  large  numbers  of  the  same  articles  is  more 
common  in  general  paralysis  of  the  insane ;  an  alcoholic 
patient  is  very  extravagant,  but  buys  different  articles. 

(16)  Lmnhar  puncture  and  examination  of  the  cerebro- 
spinal fluid  is  the  most  reliable  test  in  the  differential  diagnosis. 
Often  it  is  very  difficult  to  say  from  which  disease  a  patient  is 
suffering,  more  especially  if,  as  often  occurs,  a  general  paralytic 
has  an  alcoholic  history. 

14 


210  PSYCHOLOGICAL  MEDICINE 

Prognosis. — Savage  has  enunciated  the  following  aphorism  : 
*  To  the  alcoholic  all  things  are  possible.'  These  few  words 
contain  a  warning  which  must  never  be  forgotten.  Alcoholic 
patients  may  appear  to  be  in  a  moribund  condition,  and  may 
yet  recover  ;  their  mental  condition  may  be  such  that  dementia 
seems  to  be  the  only  possible  termination,  and  yet  within  a 
few  months  the  mental  equihbrium  is  re-estabHshed.  In  the 
acute  forms  of  alcoholic  insanity  it  is  always  advisable  to 
give  the  patient  the  benefit  of  the  doubt  and  at  any  rate  hesi- 
tate for  a  time  before  giving  a  bad  prognosis.  With  the  more 
chronic  forms,  persistent  hallucinations  are  always  a  bad  sign. 
A  very  bad  memory  in  a  young  person  is  unfavourable. 

Dipsomania. — The  dipsomaniac  is  not  a  common  drunkard 
but  one  who  suffers  from  a  periodic  impulsive  form  of  insanity 
which  manifests  itself  in  an  imperious  craving  for  alcohol. 
Some  authorities  have  compared  dipsomania  to  epilepsy, 
owing  to  its  paroxysmal  and  periodic  character.  Frequently 
no  alcohol  is  taken  between  the  attacks  and  the  man  is  a 
respectable  and  useful  member  of  society  ;  in  fact  a  dipso- 
maniac is  often  ashamed  of  his  weakness  and  constantly 
strives  against  it.  The  prodromal  symptoms  are  irritability, 
anorexia,  inability  to  fix  attention,  depression,  and  an  in- 
definite sense  of  fear  of  impending  trouble.  The  patient 
usually  struggles  hard  against  the  impulse  to  drink,  and  may 
even  go  to  his  friends  and  beseech  them  to  protect  him.  Unless 
assistance  is  given,  the  irresistible  desire  proves  too  strong, 
and  the  patient  abandons  himself  to  desperate  drinking. 
Thus  the  taking  of  alcohol  is  a  coni'plication  of  dipsomania 
and  not  a  cause.  Once  the  patient  has  started  to  drink,  he 
may  continue  mitil  an  attack  of  delirium  tremens  supervenes  ; 
on  the  other  hand,  the  bout  of  drinking  may  last  only  for  a 
few  days  or  weeks  and  terminate  spontaneously.  The  attack 
is  frequently  followed  by  a  period  of  depression,  during  which 
care  must  be  taken  to  guard  against  the  risk  of  suicide.  A 
man  may  have  only  three  or  four  attacks  in  his  lifetime,  but 
each  fresh  attack  renders  him  more  liable  to  a  recurrence. 

Morbid  Anatomy  of  Alcoholic  Insanity. — The  pathological 
changes  found  in  acute  alcoholism  are  similar  to  those 
seen  in  the  brains  of  patients  dying  from  other  toxic  agents. 
There  is  marked  oedema  of  the  brain  and  serious  congestion, 


ALCOHOLISM  211 

and  there  is  a  condition  of  chromatolysis  and  achroma- 
tolysis  in  the  nerve  cells.  In  addition  to  these  changes 
in  the  brain,  other  organs  may  show  evidence  of  chronic 
alcoholism. 

Ford  Eobertson  writes  :  '  There  are,  I  think,  three  great 
factors  that  it  is  necessary  to  recognise  in  the  pathogenesis 
of  chronic  alcohoHc  insanity  ;  namely,  (a)  the  direct  toxic 
action  of  alcohol ;  (6)  a  secondary  auto-intoxication ;  and 
(c)  the  special  reactive  qualities  of  the  individual  brain.'  ^ 

From  the  careful  study  of  the  brains  of  persons  dying 
from  acute  alcoholism,  it  is  clearly  proved  that  alcohol  has  a 
direct  toxic  effect  on  the  neurons.  Its  action  is  not,  however, 
confined  to  the  nervous  elements,  for,  if  alcohol  is  imbibed 
continually  over  a  prolonged  period,  structural  changes  of  a 
more  or  less  severe  kind  will  be  found  in  several  important 
organs  of  the  body.  These  structural  alterations  must  lead 
to  marked  disturbances  of  functions,  and,  as  Ford  Robertson 
points  out,  sooner  or  later  a  state  of  auto-intoxication  is  estab- 
lished. Now,  this  condition  of  auto-intoxication  is  probably  a 
weighty  factor  in  the  production  of  chronic  alcoholic  insanity. 
No  doubt  the  special  reactive  qualities  of  the  individual  brain 
are  often  the  determinating  factor  of  an  attack  of  insanity,  for 
some  brains  are  more  liable  than  others  to  be  damaged  by  a 
particular  toxin.  To  quote  Ford  Robertson  again  :  '  Slowly, 
but  with  steady  progression,  excretion  is  rendered  imperfect, 
and  metaboUc  processes  become  perverted.  Auto-intoxication 
has  set  in,  and  consequently  vascular  changes,  closely  re- 
sembhng  those  that  have  already  been  described  as  occurring 
in  senile  insanity  and  in  general  paralysis,  take  place  through- 
out the  body.  ...  In  many  cases  of  chronic  alcohohc 
insanity,  the  changes  in  the  cerebral  tissues  are  practically 
indistinguishable  from  those  which  are  regarded  as  typical  of 
senile  insanity,  and  in  some  they  closely  approximate  to  those 
that  are  most  characteristic  of  general  paralysis.  These 
facts  have  often  been  observed  and  remarked  upon,  but,  as 
far  as  I  have  seen,  no  one  has  satisfactorily  explained  them. 
I  maintain  that  the  true  explanation  is  simply  that  each  of 
these  three  diseases  has  an  autotoxic  basis.' 

The  pathological  changes  are  (a)  macrosco'pic,  (b)  microsco'pic. 
^  Pathology  of  Mental  Disease. 


212  PSYCHOLOGICAL  MEDICINE 

(«)  With  regard  to  macroscopic  changes  :  these,  like  the 
microscopic,  largely  depend  upon  whether  the  patient  died 
dui'ing  the  early  or  later  stages  of  the  disease.  In  its  more 
advanced  state  we  find  that  the  brain  is  below  normal  in 
weight,  and  that  the  convolutions  are  atrophied  and  shrunken. 
The  dura  and  pia-arachnoid  are  thickened,  the  latter  showing 
milky  opacities.  The  vessels  at  the  base  of  the  brain  are 
thickened.  The  ventricles  are  dilated  and  may  even  show  a 
gi'anular  condition  of  the  ependyma. 

{h)  Microscopic. — Chronic  proliferative  and  degenerative 
changes  are  found  in  the  dura  and  pia-arachnoid.  The  vessels 
show  an  advanced  state  of  endarteritis.  Bevan  Lewis  has 
drawn  attention  to  the  fact  that  the  cortical  vessels  show 
atheromatous,  fatty,  and  degenerative  change  in  their  several 
coats.  The  vessels  dipping  into  the  cortex  from  the  pia- 
arachnoid  are  of  undue  size,  coarse,  and  tortuous,  and  the  coats 
are  atheromatous  and  fatty.  The  perivascular  space  is  dis- 
tended by  numerous  lymphoid  elements.  Aneursymal  dilata- 
tions of  the  small  arterioles  are  frequently  seen.  The  cells  of 
the  neuroglia  are  hypertrophied,  and  there  is  great  abundance 
of  the  so-called  spider  cells.  Masses  of  *  colloid  bodies  '  are  to 
be  found  lying  between  the  pia  and  cortex,  and  are  the  pro- 
duct of  some  degenerative  change.  Important  alterations  are 
found  in  the  nerve  cells  and  their  processes.  Many  of  the 
cortical  nerve-cells  have  disappeared,  and  others  show  marked 
degenerative  changes,  similar  to  those  found  in  general  paralysis. 
These  will  be  described  in  discussing  the  morbid  anatomy 
of  that  disease.  Bevan  Lewis  states  that  the  second  and 
third  layers  of  the  cortex  contain  no  prominent  lesion,  but 
that  the  cells  of  the  fifth  layer  (large  motor  cells)  are  in 
an  advanced  state  of  degeneration.  The  medullated  sheaths 
are  also  affected,  and  the  axon  is  swollen  and  often  fusiforiii. 
Swellings  and  varicosities  of  the  dendrons  have  also  been  ob- 
served, and  the  gemnmlse  are  frequently  missing.  The  changes 
in  the  fine  protoplasmic  contact  granules  of  the  apical  expansions 
are  regarded  by  Andriezen  as  important  factors  in  the  produc- 
tion of  the  amnesia  so  commonly  met  with  in  alcoholic  insanity. 

Thus,  it  will  be  seen,  the  vascular,  nervous,  and  connective 
tissue  elements  in  the  brain  are  all  affected  ;  and  many  theories 
have  been  propounded  as  to  where  the  primary  change  takes 


ALCOHOLISM  213 

place.  Every  year  seems  to  bring  more  proof  that  the  first 
changes  are  to  be  found  in  the  vascular  structures.  In  con- 
clusion, it  must  not  be  forgotten  that  morbid  changes  of  a 
more  or  less  severe  nature  are  to  be  found  in  many  organs 
of  the  body. 

Treatment. — The  patient  must  be  deprived  of  his  alcohol, 
and  this  can  rarely  be  done  except  in  an  institution  or  in 
the  house  of  some  reliable  person.  Some  nurses  are  easily 
corrupted  by  bribes  and  promises,  therefore  it  is  very  neces- 
sary to  have  the  nursing  carried  out  by  persons  of  known 
character.  Some  authorities  recommend  that  the  alcohol 
should  be  gradually  withdrawn  ;  others  advise  complete  and 
immediate  withdrawal.  Undoubtedly  the  latter  method  is  the 
better  one  when  it  can  be  employed,  but  occasionally  the 
physical  state  of  the  patient  is  so  weak  that  such  a  course 
is  inadvisable,  and  the  drug  has  to  be  given  in  diminishing 
doses.  The  abrupt  method  of  withdrawal  is  possible  in 
the  great  majority  of  cases  ;  and  even  if  there  is  any  sign 
of  collapse,  this  can  usually  be  overcome  by  forced  feeding 
and  the  administration  of  drugs  such  as  strychnine,  caffein,  and 
hyoscine.  At  first  the  patient  will  be  very  restless  and  excited, 
and  he  may  develop  symptoms  such  as  vomiting  and  diarrhcea. 
Sleeplessness  is  another  trying  symptom,  and  usually  hypnotics 
have  to  be  given.  It  is  needless  to  say  that  care  must  always 
be  taken  to  prevent  the  patient  becoming  dependent  on  the 
sedative  employed,  and  in  no  case  should  he  be  told  the  name 
of  the  drug.  The  diet  should  be  liberal  and  of  a  nourishing 
nature,  and  any  tendency  to  refusal  of  food  must  at  once  be 
met  by  forced  feeding.  The  bowels  will  require  constant 
attention,  and  in  severe  cases  there  may  be  retention  of  urine. 
Hypnotic  suggestion  has  proved  of  great  value  in  the  treatment 
of  alcoholism  and  is  usually  worth  trying. 

Korsakow's  Disease  (Polyneuritic  Psychosis). — This  disease, 
as  pointed  out  by  the  observer  after  whose  name  the  disorder 
is  called,  is  usually  due  to  the  abuse  of  alcohol,  although  it  may 
occur  after  typhoid,  influenza,  diabetes,  and  chronic  poisoning 
by  mercury,  lead,  and  arsenic.  It  is  more  common  in  women 
than  in  men.  The  condition  is  a  peripheral  neuritis  associated 
with  mental  disorder.  The  peripheral  neuritis  is  that  which 
is  found  described  in  all  text-books  on  medicine.     Pressure 


214  PSYCHOLOGICAL  MEDICINE 

over  the  peripheral  nerves  excites  pain  ;  the  muscles  of  the  limbs 
are  tender,  and  the  skin  over  them  is  either  hyperaesthetic  or 
anaesthetic.  There  is  impairment  of  muscular  power  and  the 
gait  is  often  ataxic.  The  tendon  reflexes  are  usually  absent, 
but  occasionally  they  may  be  exaggerated.  Tachycardia  is 
often  present.     The  body  weight  at  first  falls. 

Mental  Symptoms. — These  are  very  characteristic.  The  illness 
may  be  ushered  in  by  delirium.  Hallucinations  of  vision  appear 
early,  and  later  hallucinations  of  the  tactual  or  other  senses 
may  be  prominent ;  at  the  same  time  there  may  be  marked 
imperception.  The  patient  mistakes  identity  and  is  usually 
disorientated.  Speech  may  be  unaffected.  The  disorders  of 
memory  are  very  characteristic  ;  there  is  no  memory  for  recent 
events  ;  illusions  of  memory  are  common  (paramnesia).  The 
patient  \\dll  romance  about  what  he  has  seen  or  heard,  fully 
believing  that  it  has  all  happened  to  him.  A  woman  will 
tell  you  that  she  has  just  come  back  from  a  walk  by  the  sea, 
although  in  point  of  fact  she  has  never  left  her  room.  It  is 
very  easy  to  suggest  these  illusions  of  memory  to  the  patients. 
Fixed  delusions  are  rare.  They  are  very  emotional  and  will 
readily  weep,  or  at  times  laugh  in  an  uncontrolled  manner. 
Sleep  is  usually  impaired. 

Prognosis. — Eecovery  after  many  months  may  take  place, 
but  it  is  not  uncommon  to  find  some  mental  enfeeblement, 
which  m  some  instances  is  so  marked  as  to  require  treatment 
in  an  asylum. 

Morbid  Anatomy. — Degeneration  of  the  peripheral  nerves  and 
atrophy  of  the  tangential  fibres  of  the  cortex  cerebri,  and  also 
atrophy  of  the  nerve  cells  in  the  cortex. 

Treatment  is  that  described  in  text-books  on  medicine,  to- 
gether with  rest  in  bed  and  good  feeding.  During  the  early 
stages  a  water-bed  may  be  found  necessary  to  prevent  bed-sores. 

Morphinism 

The  practice  of  taking  morphia  is  one  of  those  terrible 
habits  through  which  many  men  and  women  ruin  their  own 
happiness  and  the  peace  of  their  family  life.  It  is  a  matter  for 
regret  that  many  of  the  victims  of  this  habit  are  connected 
with  the  science  of  medicine,  either  as  physicians,  surgeons, 


MORPHINISM  215 

dentists,  or  nurses.  These  persons  should  well  know  the 
risk  which  they  are  running.  But  there  is  another  large 
body  of  morphia  takers,  who  begin  the  habit  in  all  innocence 
and  all  too  frequently  on  the  advice  of  their  own  medical 
attendant. 

We  live  in  an  age  which  is  intolerant  of  pain  ;  men  turn 
at  once  to  the  physician  for  a  draught  to  relieve  their  suffering. 
It  is  an  age  in  which  most  men  and  women  have  to  work 
hard  for  a  living  ;  proper  periods  of  rest,  for  various  reasons, 
cannot  be  taken,  and  bodily  fatigue,  with  all  its  vague  and 
indefinite  discomforts,  weighs  heavily  on  the  organism.  '  I 
have  no  time  to  rest,  but  I  must  have  relief,'  is  the  cry  ;  and 
in  vain  the  physician  tries  his  therapeutic  art,  until  at  length, 
-from  sheer  exasperation  or  the  importunity  of  his  patient,  he 
gives  morphia,  the  certain  panacea  of  all  pain.  The  effect 
is  almost  miraculous — the  misery  and  suffering  fade  before 
returning  energy  and  animation.  Work  which  was  formerly 
unbearable  is  now  a  pleasure  and  once  again  life  seems  worth 
living.  Twenty-four  hours  pass  away,  only  to  see  a  return 
of  the  original  weary  feeling,  and  once  again  the  dose  is  sought 
and  relief  obtained.  Week  by  week  and  month  by  month, 
often  in  ignorance,  the  unhappy  man  relies  more  and  more 
on  his  daily  draught.  The  dose  which  formerly  gave  relief 
has  had  to  be  increased  continually.  The  patient  sooner  or 
later  becomes  anxious  and  maybe  fears  that  he  is  becoming 
dependent  upon  the  drug.  He  salves  his  conscience  with 
the  thought  that  when  he  gets  stronger  he  will  give  it  up, 
but  that  day  never  comes.  The  drug,  which  was  formerly 
taken  to  relieve  pain,  is  now  almost  a  necessary  food.  When 
once  the  habit  has  been  formed,  it  is  practically  outside  the 
limits  of  human  purpose  to  overcome  it.  If  the  patient  is  of 
strong  character,  the  habit  may  for  years  be  kept  within 
bounds  ;  but  whether  the  patient  be  strong  or  weak,  the  day 
ultimately  comes  when  the  poison  gains  the  upper  hand — the 
result  is  mental  and  physical  collapse. 

etiology. — The  common  period  of  life  for  acquiring  this 
habit  is  between  twenty  and  fifty  years  of  age,  l)ut  most  people 
develop  it  before  thirty-five.  Both  sexes  seem  to  be  almost 
equally  affected.  A  certain  percentage  of  patients  have  a 
neurotic  inheritance,  l)ut  a  large  number  have  no  such  history. 


216  PSYCHOLOGICAL  MEDICINE 

As  the  drug  is  a  costly  one,  the  habit  is  chiefly  confined  to 
the  upper  and  middle  classes.  As  a  rule,  morphia  is  primarily 
given  or  taken  for  the  relief  of  pain. 

Mental  Symptoms.- — In  the  first  place  morphia  gives  an 
exhilarating  effect,  with  a  feeling  of  increased  mental  vigour 
and  power.  It  is  often  effectual  in  dulling  the  sense  of  care 
and  annoyance.  With  its  continued  use  sj^mptoms  of  mental 
and  moral  failure  begin  to  develop  ;  but  the  onset  varies  greatly 
in  different  individuals  and  is  largely  dependent  upon  the 
amount  of  morphia  taken.  One  person  will  show  mental 
symptoms  after  a  few  months,  in  others  there  is  nothing 
very  noticeable  even  after  many  years.  In  time  the  memory 
weakens,  there  is  lessened  power  of  attention,  and  the 
intellectual  powers  readily  fatigue.  Nevertheless,  after  a  dose  of 
the  drug,  the  mental  equilibrium  may  be  re-established,  and  the 
patient  is  once  more  mentally  active  and  intellectiially  brilliant. 

If  there  is  one  symptom  which  more  than  another  is  char- 
acteristic of  drug  poisoning,  it  is  riioral  deterioration.  Un- 
truthfulness is  common,  and  there  is  a  tendency  for  the  patient 
to  distort  the  acts  and  sayings  of  others  so  as  to  lend  colour 
to  his  own  warped  judgment.  It  is  indeed  distressing  to 
see  a  generous  nature  gradually  being  undermined  and  slowly 
but  surely  being  replaced  by  a  fault-finding  and  uncharitable 
spirit.  During  acute  intoxication  hallucinations  and  other 
sensory  disturbances  may  be  experienced  ;  but  hallucinations 
are  not  common  unless  the  morphia  is  supplemented  by  cocaine. 
Periods  of  excitement  and  general  confusion  may  occur  ;  at 
other  times  there  may  be  apathy  or  depression.  The  mental 
condition  of  the  patient  may  be  such  that  it  is  necessary  for 
him  to  be  placed  under  certificates.  This  procedure  may  be 
of  great  value  to  the  patient,  as  it  may  be  the  means  of  his 
complete  restoration  to  health. 

Physical  Symptoms. — Frequently  there  is  anorexia"^and 
constipation  and  general  derangement  of  the  alimentary 
tract.  The  pulse  may  be  slow  and  even  irregular,  and  the 
blood-pressure  is  lowered.  The  patient  looks  very  anaemic 
with  a  parchment-like  appearance  of  skin.  The  secretions 
are  diminished,  but  at  times  there  is  profuse  perspiration. 
There  is  general  muscular  failure  and  the  movements  may 
be  tremulous.     The  pupils  are  usually  myotic.     General  and 


MORPHINISM  217 

special  sensation  may  be  affected.     In  the  male,  there  may  be 
impotence  ;    in  the  female,  amenorrhcea  and  sterility. 

Course. — This  varies  greatly  in  different  individuals ;  in 
some  the  course  is  very  rapid,  while  in  others  there  are  no 
severe  symptoms  for  many  years. 

Diagnosis. — This  is  not  always  easy,  as  morphia  takers  are 
very  secretive,  and  unless  surprised  in  the  act  of  taking  a 
dose,  may  evade  discovery  for  a  long  time.  The  body  should 
be  examined  for  scars  and  discoloured  patches,  which  are 
brought  about  by  the  long-continued  use  of  a  hypodermic 
syringe.  The  only  certain  method  of  making  a  true  diagnosis 
is  to  put  the  patient  in  bed  in  charge  of  reliable  nurses.  If 
.  urgent  symptoms  arise,  the  administration  of  a  dose  of  morphia 
will  re-establish  the  mental  equilibrium  in  the  event  of  the 
person  being  a  morphia  taker.  This  is  true  of  all  drugs,  and  is 
a  useful  method  of  confirming  a  suspected  diagnosis. 

Prognosis. — When  the  habit  is  begun  early  in  life  and  in 
an  individual  with  an  unstable  inheritance,  the  prognosis  is 
not  good.  Patients  who  are  in  good  health  and  are  willing  to 
be  treated  do  well,  but  many  relapse  even  when  the  habit 
has  been  broken  for  some  months. 

Treatment. — The  treatment  may  be  divided  into  (a)  pro- 
'pliyladic,  (b)  curative,  (a)  Medical  men  should  be  exceed- 
ingly careful  not  to  give  morphia  for  ordinary  ills  and  pains. 
Women  will  often  ask  for  it  to  relieve  uterine  pain  or  neuralgia 
of  all  sorts ;  such  requests  should  be  definitely  refused,  and  a 
decision  once  given  should  be  adhered  to  in  spite  of  all  entreaty. 
If  an  urgent  condition  demands  that  morphia  should  be  given, 
the  patient  should  not  be  told  what  drug  he  is  taking ;  and  if 
by  any  chance  this  is  found  out,  the  patient  should  be  clearly 
warned  as  to  the  risk  of  its  continued  use.  (h)  The  curative 
treatment  can  only  be  undertaken  if  the  patient  is  willing  to 
place  himself  under  care,  or  in  the  event  of  his  becoming 
certifiably  insane.  The  first  thing  to  do  is  to  find  a  reliable 
house  and  trustworthy  nurses  ;  and  this  is  by  no  means  easy, 
as  any  laxity  may  interfere  with  successful  treatment. 
Patients  will  bribe  nurses  to  procure  morphia  for  them,  and 
for  this  reason  too  great  care  cannot  be  taken  in  selecting  the 
nurse.  Complete  isolation  is  requisite,  and  every  parcel  or  letter 
must  be  opened  by  the  nurse  in  the  presence  of  the  patient. 


218  PSYCHOLOGICAL  MEDICINE 

There  are  three  methods  of  withdrawing  the  drug  :  either 
at  once  stopping  it  completely,  rapidly  withdrawing  it,  or 
gradually  withdrawing  it  in  steadily  decreasing  doses.  The 
complete  and  rapid  withdrawals  are  by  far  the  best  ways  when 
possible,  but  in  many  feeble  patients  are  too  dangerous,  as 
fatal  collapse  may  take  place  within  thirty-six  hours.  Each 
case  must  be  decided  on  its  own  merits.  Under  any  circum- 
stances the  patient  must  be  put  to  bed.  Good,  supporting, 
and  nourishing  diet  must  be  given.  Alcohol  is  nearly  always 
required.  Abstinence  symptoms  may  occur  within  the  first 
two  days  after  withdrawal.  Insomnia  and  intense  restlessness 
are  common  ;  the  patient  may  become  very  agitated,  and  even 
acute  excitement  may  supervene.  Diarrhoea  may  be  a  trying 
symptom  and,  if  severe,  requires  treatment.  Twitchings, 
cramps,  and  violent  pains  occur  in  severe  cases.  Hiccough 
and  yawning  may  be  persistent.  The  mental  state  is  usually 
one  of  great  depression  with  a  sense  of  extreme  weakness. 
Fatal  collapse  may  take  place  without  any  warning.  The 
patient  becomes  unconscious  with  raised  temperature  and 
pulse  rate  and  symptoms  of  pneumonia.  This  condition  may 
last  for  two  or  three  days,  and  death  then  takes  place  from 
failure  of  the  respiratory  centre.  Warm  baths  at  night  will 
be  found  very  soothing  to  patients  who  are  very  restless,  and 
sleep  can  frequently  be  induced  in  this  way.  Hypnotics  may 
be  necessary,  and  some  authorities  recommend  large  doses  of 
bromide  of  potassium.  Strychnine  given  hypodermically  is 
invaluable  in  the  treatment.  Chloral  is  at  times  useful  in 
these  cases.  Bicarbonate  of  soda  is  recommended  by  some 
authorities  to  be  used  as  a  routine  practice  to  stop  gastric 
hyper-secretion.  If  the  treatment  is  successful,  the  physical 
health  of  the  patient  begins  to  improve  and  sleep  comes  naturally. 
It  is  advisable  to  keep  the  patient  under  supervision  as  long 
as  possible. 

COCAINISM 

Cocaine  is  usually  taken  in  conjunction  with  morphia  in 
order  to  allay  the  irritation  set  up  by  the  latter  drug.  It 
produces  nervous  symptoms  much  more  readily  than  morphia, 
and  it  is  often  the  addition  of  cocaine  that  causes  morphia 
takers  to  become  insane. 


COCAINISM  219 

etiology. — Tlie  aetiology  is  very  similar  to  that  of  morphia. 
Cocaine  is  taken  either  hypodermically  or  in  the  form  of  snuff 
or  wine  to  allay  pain  and  discomfort,  and  by  some  patients  to 
prevent  the  feeling  of  hunger.  It  is  a  costly  drug,  and  its 
use  is  therefore  confined  to  the  wealthier  classes. 

Mental  Symptoms. — It  creates  a  mild  mental  excitement  with 
a  sense  of  increased  vigour.  In  large  doses  it  often  produces 
acute  delirium.  With  prolonged  use  there  is  a  general  failure 
of  both  mental  and  physical  power.  The  patient  becomes 
talkative  and  writes  innumerable  letters.  He  is  often  over- 
bearing in  his  manner  and  wild  in  his  conversation.  As  time 
passes  he  becomes  suspicious  and  irritable  and  his  memory 
and  power  of  attention  fail.  Without  any  warning  vivid 
-hallucinations  may  appear.  He  sees  and  hears  things  which 
terrify  him.  A  common  symptom  is  the  sensation  of  rolling 
sand  under  the  skin  ;  this  may  be  misinterpreted  into  electrical 
currents,  or  bring  about  the  belief  that  there  are  insects  all 
over  the  body.  The  patient  more  and  more  distrusts  his 
relatives  and  friends  and  may  carry  firearms  and  knives  to 
protect  himself.  Slowly  delusions  of  persecution  are  evolved 
and  the  man  becomes  a  source  of  danger  to  himself  and  the 
community.  These  patients  ought  to  be  placed  under  care  as 
soon  as  possible. 

Physical  Symptoms. — There  is  a  great  disturbance  of  general 
nutrition,  with  rapid  loss  of  body  weight.  The  appetite  is 
bad,  and  there  are  dyspeptic  symptoms  together  with  con- 
stipation. The  eyes  are  sunken.  The  muscles  become  wasted 
and  tremulous.  Complaint  may  be  made  of  pain  in  the  limbs 
or  joints.  Convulsions  may  occur.  The  circulation  becomes 
more  feeble,  and  there  is  a  tendency  to  syncope.  Albuminuria 
is  found  in  some  cases.  The  patient  is  sleepless  and  more 
and  more  relies  on  the  drug  to  obtain  relief.  Sexual  power 
fails,  but  from  time  to  time  there  may  be  outbursts  of  sexual 
excitement. 

Course. — As  soon  as  mental  symptoms  appear,  if  the  cocaine 
is  not  stopped,  the  patient  rapidly  becomes  very  insane.  He 
usually  makes  wild  accusations  of  all  kinds  against  his  friends. 
His  emotional  state  varies  from  that  of  exaltation  and  excite- 
ment to  dejection.  Finally,  he  becomes  a  dangerous  member 
of  society.     Under  treatment  the  urgent  symptoms  soon  pass 


220  PSYCHOLOGICAL  MEDICINE 

off,  and  the  withdrawal  of  cocaine  is  usually  less  acutely  felt 
by  the  patient  than  that  of  morphia.  In  time  recovery  may 
take  place,  but  there  is  always  a  danger  of  some  of  the  delu- 
sions of  suspicion  persisting. 

Prognosis. — In  mild  cases  the  prognosis  is  fairly  good,  but  if 
the  habit  is  of  long  standing,  complete  recovery  is  not  common. 

Treatment. — The  treatment  is  in  every  way  similar  to  that 
described  under  Morphinism.  As  a  rule  it  is  more  often 
necessary  to  place  the  patient  under  certificates  as  a  person 
of  unsound  mind.  Strychnine  is  a  useful  drug  in  the  treat- 
ment of  cocainism. 

Plumbism 

The  toxic  effects  of  lead  on  the  nervous  system  are  well 
known  and  are  fully  described  in  text-books  on  medicine. 
From  time  to  time  cases  of  insanity  occur  in  which  the 
exciting  cause  is  lead-poisoning  ;  this  form  of  mental  dis- 
order is  called  by  several  names,  such  as  lead  encejjJialo'pathj 
or  saf.urni7ie  e^icejjlialopathy. 

.^Etiology. — Usually  the  intoxication  is  of  a  chronic  nature 
produced  by  working  in  lead  or  drinking  water  contaminated 
by  lead.  Savage  records  a  case  in  which  the  free  use  of  a 
lead  lotion  on  a  large  open  wound  induced  lead-poisoning 
and  subsequent  insanity. 

Mental  Symptoms. — The  physical  symptoms  usually  appear 
before  the  mental  disturbances.  It  is  very  rare  for  insanity 
to  develop  without  some  premonitory  symptoms.  These  latter 
consist  of  insomnia,  headache,  and  terrifying  dreams.  Hallu- 
cinations, especially  of  the  visual  type,  begin  to  appear  at 
night.  The  patient  slowly  becomes  confused,  and  ideation  is 
slow  ;  sooner  or  later  he  shows  signs  of  restlessness.  As  time 
passes,  the  excitement  becomes  more  marked  and  may  lead 
to  wild  delirium.  Auditory  and  visual  hallucinations  terrify 
the  patient.  The  excitement  may  diminish,  but  is  usually 
followed  within  a  few  hours  by  an  accession  of  furious  mania. 
There  is  great  confusion  of  thought,  and  the  memory  is  un- 
certain. Dehisions  of  persecution  may  develop.  The  mental 
state  may  be  that  of  coma,  which  is  sometimes  comphcated 
with  convulsive  seizures. 


PLUMBISM  221 

Physical  Symptoms. — The  physical  symptoms  are  usually 
well  marked  and  as  a  rule  appear  before  any  signs  of  mental 
disturbance.  They  consist  of  colic,  blue  lines  on  the  gums, 
stomatitis,  wrist-drop,  tremors,  peroneal  paralysis,  etc.  Food 
is  frequently  refused.  Convulsive  seizures  may  occur.  Vision 
may  be  lost  temporarily  or  permanently. 

Com^se. — Some  cases  of  insanity  due  to  lead-poisoning 
closely  resemble  general  paralysis  of  the  insane,  and  care  must 
be  taken  not  to  confuse  the  two  diseases.  As  soon  as  the 
poison  is  withdrawn,  the  patient  usually  makes  rapid  progress 
towards  recovery.  A  certain  percentage  do  not  quite  regain 
their  former  mental  vigour,  but  remain  more  or  less  intel- 
lectually weak.  In  fatal  cases  either  coma  or  severe  convul- 
sions supervene  ;  a  few  succumb  to  exhaustion  following  the 
intense  excitement. 

Diagnosis. — The  diagnosis  ought  not  to  be  difficult  if  the 
patient  is  examined  carefully  for  physical  signs  of  lead- 
poisoning. 

Prognosis. — The  prognosis  is  usually  favourable  if  the  case 
is  of  recent  origin.  When  coma  or  convulsions  supervene, 
the  outlook  is  not  hopeful. 

Treatment. — The  treatment  is  similar  to  that  of  general 
lead-poisoning.     A  supporting  diet  should  be  given. 


222  PSYCHOLOGICAL  MEDICINE 


CHAPTEE  XIV 

GENERAL  PARALYSIS   OF  THE  INSANE 

General  Paralysis  of  the  Insane  is  now  frequently  known 
by  the  name  of  Dementia  Paralytica.  It  is  a  disease  of  the 
nervous  system  and  is  not  in  the  ordinary  sense  of  the  word 
an  insanity.  The  patient  becomes  insane  because  the  damage 
done  to  the  brain  by  the  disease  is  so  severe  that  mental 
disorder  results.  Whatever  the  cause,  whether  it  is  cerebral 
tumour,  laceration,  or  the  Uke,  if  the  injury  to  the  cerebral 
structures  is  extensive,  mental  disorder  v/ill  supervene.  In 
some  cases  of  general  paralysis  the  mental  change  is  nothing 
more  than  a  progressive  weakening  of  intellect,  whereas  the 
physical  symptoms  may  be  numerous  and  severe.  Insanity 
must  be  looked  upon  rather  as  a  complication  of  general 
paralysis,  though  undoubtedly  a  common  compUcation,  for  in 
some  patients  who  die  from  this  disease  the  mental  symptoms 
are  never  so  acute  as  to  require  any  very  special  treatment. 
On  the  other  hand,  mental  disorder  of  a  very  acute  kind  is 
frequently  met  with  in  general  paralysis,  and  it  may  be  the 
symptom  which  calls  most  urgently  for  treatment.  There  is 
no  special  form  of  mental  disorder  pecuKar  to  this  disease, 
and  therefore  the  insanity  does  not  assist  us  in  the  diagnosis. 
To  sum  up,  general  paralysis  may  be  looked  upon  as  a  pro- 
gressive nervous  disease,  characterised  clinically  by  progres- 
sive mental  and  physical  deterioration. 

-ffitiology. — This  disease  is  most  common  between  the 
ages  of  thirty  and  fifty  years,  but  it  may  occur  either  earlier 
or  later  in  life.  The  male  is  much  more  prone  to  it  than  the 
female,  in  the  ratio  of  live  to  one.  General  paralysis  is  rare 
among  the  uncivilised  races,  and  it  is  very  rife  in  the  highly 
civiUsed   nations.    Large   towns   and   manufacturing   centres 


GENERAL  PARALYSIS  OE  THE  INSANE  223 

furnish  most  cases  of  the  disease.  Heredity  does  not  play 
a  very  important  part  in  the  causation  of  general  paralysis, 
and  a  large  percentage  of  these  patients  have  no  special  history 
of  nervous  instability  in  their  immediate  relatives. 

Syphilis  is  now  regarded  by  all  authorities  as  the  essential 
factor  in  the  disease,  though  there  is  little  doubt  that  there 
are  other  factors  which  play  important  secondary  parts  in 
its  production.  Sexual  excess,  alcoholism,  and  head  injuries 
are  often  determining  causes.  The  date  of  this  syphilitic 
infection  is  usually  about  fifteen  or  twenty  years  previous  to 
the  development  of  the  disease  under  review,  but  it  may  be  a 
much  shorter  or  a  longer  period.  It  is  common  to  find  that 
the  younger  the  individual  is  when  he  contracts  syphilis,  the 
greater  the  number  of  years  before  the  general  paralytic  symp- 
toms show  themselves.  The  fact  that  only  about  three  per 
cent,  of  syphilitic  persons  develop  general  paralysis  later  in 
life  clearly  shows  that  there  must  be  other  determining  causes. 
Neither  is  it  satisfactorily  proved  that  the  untreated  cases 
are  more  prone  to  it  than  the  properly  treated,  as  many  women 
must  become  infected  and  yet  remain  undiagnosed,  as  is 
proved  by  the  number  who  give  positive  Wassermanns  later  in 
life,  and  yet  general  paralysis  among  women  is  comparatively 
rare.  On  the  other  hand,  it  is  curious  that  in  the  juvenile 
general  paralytics  females  are  more  commonly  met  with  than 
males.  Mott  has  suggested  that  there  may  be  a  special 
neurotoxic  variety  of  the  spirochsete  pallida. 

Sexual  excess  was  formerly  held  by  some  authorities  to  be 
the  primary  cause  of  general  paralysis.  No  doubt  excess  of 
this  kind  does  produce  symptoms  which  in  many  ways  closely 
resemble  those  found  in  dementia  paralytica,  for  they  are 
symptoms  of  severe  nervous  prostration.  Sexual  excess  leads 
to  nervous  and  muscular  irritability  and  the  early  symptoms 
of  general  paralysis  are  commonly  of  this  type.  There  is  no 
doubt  that  sexual  excess  combined  with  syphilis  makes  the 
latter  a  much  more  serious  disease,  and  in  this  way  it  may 
be  the  exciting  cause  which  finally  determines  the  onset  of 
general  paralysis  ;  also  in  locomotor  ataxy  it  is  very  common 
to  find  a  history  of  sexual  excess. 

It  may  be  said  at  once  that  it  is  now  almost  conclusively 
proved  that  alcohol  per  se  does  not  produce  general  paralysis. 


224  PSYCHOLOGICAL  MEDICINE 

On  the  other  hand,  when  associated  with  syphilis  the  combina- 
tion is  a  dangerous  one  and  very  prone  to  engender  this  disease. 
Great  care  must  be  taken  not  to  confuse  alcohol  as  a  cause 
and  alcohol  as  a  symptom,  as  frequently  one  of  the  earliest 
symptoms  of  general  paralysis  is  a  tendency  to  drink. 

Before  leaving  the  question  of  getiology,  it  is  necessary  to 
refer  to  some  other  points  which  should  be  considered  under 
this  head.  A  head-injury  of  a  more  or  less  serious  nature 
is  not  uncommonly  met  with  in  the  history,  and  no  doubt 
it  must  be  regarded  as  an  exciting  cause.  The  nervous 
system  may  be  in  an  unstable  state,  the  result  of  some  pro- 
found metabolic  change  brought  about  by  a  toxin  such  as 
syphilis,  and  the  concussion  which  the  head-injury  must  of 
necessity  produce  may  be  the  starting  point  of  a  more  active 
degeneration.  Some  authorities  have  attached  importance  to 
sunstroke  as  a  cause,  but  if  it  plays  any  part  it  must  be  a  role 
similar  to  that  of  head-injury.  Great  or  prolonged  mental 
and  physical  stresses  may  produce  profound  nutritional 
change  and  in  this  way  probably  are  powerful  elements  in 
the  aetiology  of  general  paralysis. 

Types  of  Mental  Disorder.- — As  already  pointed  out,  de- 
mentia paralytica  is  a  physical  disease  and  the  mental  disorder 
is  merely  a  symptom  and  complication.  The  forms  of  mental 
disorder  met  with  in  this  disease  are  very  varied  and  may 
even  alter  during  the  course  of  the  complaint.  If  the  patient 
lives,  long  enough  profound  dementia  is  the  termination  so 
far  as  the  mental  aspect  is  concerned.  Some  cases  show  a 
slow  progressive  mental  deterioration  from  the  very  beginning 
with  no  emotional  disturbances  such  as  depression  or  excite- 
ment. Expansive  delirium  is  a  common  form  of  mental  dis- 
order during  some  stage  of  the  disease.  It  may  appear  early 
or  late,  but  in  some  cases  it  is  entirely  absent  throughout  the 
illness.  The  mental  aspect  may  be  that  of  melancholia  or 
hypochondriacal  melancholia  ;  a  somewhat  smaller  number  of 
patients  exhibit  symptoms  of  excitement,  usually  of  a  very 
violent  kind.  Patients  with  prominent  delusions  of  perse- 
cution are  more  rarely  met  with.  Great  mental  confusion  and 
stupor  are  occasionally  observed. 

Prodromal  Stage. — General  paralysis  may  first  show  itself 
by  failure  of  the  intellectual  faculties  or  by  some  disorder  of 


GENERAL  PARALYSIS  OF  THE  INSANE  225 

the  sensory  or  motor  apparatus.  Nevertheless,  whatever  the 
first  noticeable  symptom  may  have  been,  on  looking  back  the 
friends  of  the  patient  will  certainly  state  that  for  a  long  time 
previously  they  had  remarked  that  the  mental  attitude  of  the 
man  has  been  changing.  At  the  risk  of  being  thought  tedious, 
the  student  may  be  reminded  that  the  failure  will  follow  the 
law  of  dissolution  already  enimciated,  and  this  law  will  be 
followed  whether  the  symptoms  belong  to  the  psychical  or  the 
physical  domain. 

First,  what  are  the  mental  changes  ?  Quite  early  in  the 
course  of  the  disease  a  condition  of  mental  irritability  declares 
itself.  The  formerly  calm  nature  becomes  quick  and  irritable  ; 
■the  man  shows  loss  of  control  in  words  and  actions  ;  every- 
thing has  to  be  done  at  once  and  as  he  wishes.  There  are 
outbursts  of  temper  upon  the  sHghtest  provocation  ;  instead 
of  being  courteous  and  poUte  to  friends  and  strangers,  the 
patient's  manner  becomes  rude  and  overbearing.  The  memory 
may  be  faulty  and  uncertain,  attention  and  power  of  appUca- 
tion  fail.  The  business  man  becomes  apathetic  and  indifferent 
about  his  work,  forgetful  of  his  appointments,  and  he  rapidly 
loses  money  ;  or  he  may  embark  on  some  gigantic  scheme, 
and  in  this  way  squander  all  his  wealth.  The  moral  sense 
begins  to  deteriorate,  the  patient  may  show  loss  of  control 
by  using  offensive  language,  or  his  actions  may  be  objection- 
able and  serious  breaches  of  the  moral  laws  may  occur.  The 
emotions  are  frequently  in  an  unstable  condition  ;  the  man 
will  be  hilarious  at  one  moment  and  weeping  at  the  next. 
There  is  commonly  a  period  of  over-activity  and  restlessness, 
the  patient  is  never  quiet  for  a  moment,  and  his  days  are 
spent  in  a  whirl  of  excitement.  Notwithstanding  his  bom- 
bastic and  egotistical  manner,  he  is  easily  swayed  by  any  man 
w^ho  understands  his  mental  state  and  knows  how  to  treat 
him.  Some  patients  are  sullen,  some  depressed,  whereas  others 
are  merely  confused. 

Wliile  all  these  changes  are  taldng  place  in  the  mental 
condition  of  the  patient,  equally  important  symptoms  may  be 
observed  in  the  physical  state.  Headache  may  be  an  early 
symptom.  Errors  in  speech  and  writing  may  be  frequent, 
and  tremors  of  facial  and  Ungual  muscles.  The  recently 
acquired  accomplishments  begin  to  fail.     General  and  special 

15 


226  PSYCHOLOGICAL  MEDICINE 

sensation  may  be  affected,  and  even  definite  hallucinations 
may  occur.  The  pupils  frequently  become  sluggish  in  their 
reaction  to  light,  and  the  consensual  reflex  may  be  entirely 
lost.  The  knee-jerks  are  usually  affected  and  may  be  exag- 
gerated, diminished,  or  lost.  Convulsive  seizures  of  an  epi- 
leptic nature  may  be  quite  an  early  symptom,  or  the  seizures 
may  consist  of  a  transitory  deafness,  blindness,  or  aphasia. 
Unilateral  convulsions  without  loss  of  consciousness  are  very 
suggestive  of  general  paralysis.  There  may  be  a  general 
failure  of  nutrition,  and  the  bodily  functions  may  be  dis- 
ordered. Sleeplessness  is  a  prominent  symptom  in  some  cases, 
whereas  in  others  there  is  a  tendency  to  drop  off  to  sleep  at 
all  hours  of  the  day.  In  the  early  stages  of  general  paralysis 
a  single  glass  of  wine  may  make  the  patient  appear  to  be  in- 
toxicated. This  latter  symptom  is  important  to  bear  in  mind, 
as  many  men  have  got  into  serious  trouble  and  have  been 
accused  of  drunkenness,  whereas  they  were  in  reaHty  in  the 
incipient  stage  of  dementia  paralytica.  The  prodromal  stage 
may  last  for  several  months,  and  the  symptoms  are  frequently 
overlooked  until  something  serious  occurs,  such  as  a  severe 
seizure  or  some  alarming  mental  symptom.  Pupillary  changes 
may  take  place  in  other  maladies,  but  when  there  is  definite 
Argyll-Eobertson  pupil  it  indicates  sorae  serious  organic  disease. 
Mental  Symptoms. — -The  mental  disturbances  already  briefly 
described  under  the  heading  of  Prodromata  gradually  become 
more  developed.  The  symptoms  are  largely  dependent  upon 
the  mental  type  of  the  disorder.  Nevertheless,  whatever 
form  the  mental  disorder  may  assume,  there  is  one  predomi- 
nating tendency  running  throughout  the  illness  and  that  is 
progressive  deterioration.  Frequently  there  is  marked  cloud- 
ing of  consciousness,  as  evidenced  by  the  mental  confusion. 
The  general  paralytic  is  like  a  man  in  a  dream,  he  loses  all 
power  of  comparison,  his  ideas  and  feelings  are  so  vivid  that 
he  accepts  them,  no  matter  how  fantastic  and  extravagant 
they  may  be.  ];)issolution  clearly  shows  the  scaffolding  upon 
which  the  mind  of  man  is  built  :  a  man  believes  himself  to 
be  the  most  reasonable  being,  but  after  all  he  is  largely 
guided  by  his  sensations  and  feelings.  This  view  is  corro- 
borated by  the  case  of  the  general  paralytic ;  he  feels  strong 
and  believes  that  he  is  the  strongest  man  in  the  world  ;    he 


GENERAL  PARALYSIS  OF  THE  INSANE  227 

feels  intensely  happy  and  acts  accordingly  ;  whereas  another 
man  feels  miserable  and  believes  that  he  is  going  to  die.  The 
judgment  is  impaired  early  in  the  disease,  and  there  is  pro- 
gressive failure  of  business  capacity. 

Memory  frequently  becomes  more  and  more  uncertain, 
and  as  the  disease  progresses  the  remote  memory  suffers  as 
well  as  the  more  recent.  This  progressive  amnesia  is  very 
instructive,  for  the  man  first  loses  power  of  recall  of  proper 
names  and  memory  for  recent  events  ;  as  time  passes  ideas  in 
general  begin  to  fail,  and  the  feelings  become  blunted  ;  he  at 
the  same  time  forgets  his  nouns  and  verbs,  and  interjections 
only  may  be  retained.  Actions  become  less  frequent  and 
.more  primitive  until  finally  gestures  alone  are  left,  and  they 
in  turn  disappear,  and  the  once  reasoning  man  finally  sinks  to 
the  level  of  the  infant  mind,  but  minus  all  the  potentialities 
of  the  latter. 

To  return  :  in  the  earlier  stages  of  the  disease  illusions  of 
memory  (paramnesia)  are  not  uncommon.  The  patient  relates 
incidents  which  occur  to  his  mind  as  if  they  had  been  part 
of  his  own  experience.  He  will  describe  in  a  graphic  manner 
how  he  led  a  victorious  army  across  Europe,  or  how  he  gained 
the  mastery  of  the  seas  by  an  ironclad  that  could  fly,  float, 
or  travel  at  the  bottom  of  the  sea  at  the  rate  of  a  hundred  miles 
an  hour.  Such  a  man  will  talk  of  his  enormous  wealth  and  in 
the  same  breath  ask  you  to  lend  him  sixpence.  The  restless- 
ness and  irritability  which  we  have  already  referred  to  become 
very  prominent;  symptoms  in  some  cases.  The  patient  is  never 
quiet  for  a  moment.  He  is  up  in  the  early  hours  of  the 
morning,  and  if  not  controlled,  may  be  compromising  himself, 
his  family,  and  partners  in  business,  in  some  wild  scheme. 
He  writes  cheques  which  far  exceed  his  balance  at  the  bank 
and  not  uncommonly  purchases  property  and  articles  which 
he  neither  requires  nor  can  pay  for.  Telegrams  are  despatched 
broadcast ;  for  at  first  he  seldom  stops  to  write,  but  wires  to 
friends,  acquaintances,  and  strangers.  If  placed  under  control, 
he  frequently  spends  his  days  in  correspondence.  He  destroys 
books  by  writing  his  letters  on  the  fly-leaf  and  lighting  his 
pipe  with  the  other  pages.  He  is  very  benevolent  and  writes 
cheques  for  large  sums  and  gives  them  to  comparative  strangers. 
The  emotional  attitude  is  one  that  is  constantly  changing  ;  the 


228  PSYCHOLOGICAL  MEDICINE 

patient  msij  suddenly  get  into  a  violent  passion,  and  a  moment 
later  may  be  weeping  or  laughing. 

We  will  now  pass  on  to  consider  the  various  types  of  mental 
disorder  more  in  detail. 

(1)  The  expansive  form. — This  is  not  the  most  common 
type,  but  as  it  is  the  classical  variety  it  will  be  considered  first. 
The  mental  aspect  is  one  of  exaggerated  well-being.  There  is 
general  exaltation  with  extravagant  ideas  of  wealth,  social 
position,  physical  strength,  and  the  like.  Whatever  these 
patients  do  is  the  best,  and  no  one  can  equal  them  in  ability  ! 
If  they  sing,  their  vocal  powers  are  '  superb  '  ;  and  if  a  song 
is  suggested,  they  will  treat  their  audience  to  a  series  of 
discordant  sounds,  either  shouted  at  the  full  limit  of  their 
respiratory  powers,  or  uttered  in  a  monotone,  and  closely 
resembling  the  singing  of  a  drunken  man.  In  many  ways 
they  simulate  the  intoxicated  person  both  by  their  manners 
and  speech,  and  it  is  not  uncommon  in  the  early  stages 
of  the  disease  for  them  to  be  accused  of  drinking. 

The  delusions  are  so  varied  and  so  extraordinary  that  it 
would  occupy  many  pages  even  to  describe  a  few  of  them.  A 
man  will  not  be  content  with  the  title  of  Alexander  the  Great, 
but  will  sign  himself  also  Napoleon,  Wellington,  the  Black 
Prince,  King,  Emperor,  Pope.  Another  may  find  that  there 
is  no  title  on  the  earth  great  enough  for  him  and  he  assumes 
the  position  of  the  Deity.  Everything  in  the  world  belongs 
to  him  and  he  looks  upon  the  hospital  as  one  of  his  palaces. 
In  addition  to  this  exaltation  there  may  be  a  great  amount 
of  excitement  and  restlessness.  The  excitement  of  general 
paralysis  is  more  acute  and  unreasoning  than  that  of  ordinary 
mania.  All  the  symptoms  of  acute  mania  are  present,  but  in 
addition  there  are  the  physical  signs  of  dementia  paralytica. 
Convulsive  seizures  are  common.  Hallucinations  of  sight  and 
hearing  may  be  present,  but  they  are  not  very  frequently  met 
with.  '■ 

(2)  The  depressed  and  melancholic  form  of  general  para- 
lysis appears  to  be  increasing  in  frequency  and  is  more 
commonly  met  with  than  it  used  to  be.  Many  of  these 
patients  are  hypochondriacal  and  believe  that  they  are  suffer- 
ing from  manifold  diseases.  Memory  and  judgment  fail  and 
they  become  incapable  of  following  their  usual  occupations. 


GENERAL  PARALYSIS  OF  THE  INSANE  229 

Headaches  are  a  frequent  and  trying  symptom.  Sooner  or 
later  definite  delusions  develop  and  may  be  of  any  kind. 
Self-accusation  is  not  uncommon.  One  man  will  believe  that 
he  has  typhoid  fever  ;  another  that  his  body  is  decaying  and 
that  his  various  organs  are  rotten.  At  times  there  is  no  small 
degree  of  exaltation  in  their  misery  ;  a  general  paralytic  with 
the  idea  of  bowel  obstruction  may  beheve  that  his  abdomen 
is  filled  with  thousands  of  tons  of  fseces.  Food  may  be 
refused,  and  hallucinations  of  taste  are  not  uncommon.  It  is 
in  those  cases  of  dementia  paralytica  in  which  the  depressed 
symptoms  are  most  prominent  that  hallucinations  of  the 
various  senses  are  more  frequently  met  with.  Some  authori- 
ties state  that  hallucinations  are  rare  in  general  paralysis,  and 
this  for  the  most  part  is  true  ;  but  there  are  notable  exceptions, 
and  it  would  not  be  safe  to  reject  the  diagnosis  of  this  disease. 
because  of  the  presence  of  hallucinations  in  any  given  case. 
There  is  usually  a  greater  amount  of  mental  confusion 
than  in  ordinary  melancholia  ;  but,  except  for  this  and 
the  physical  symptoms  of  organic  disease,  the  mental  state 
closely  resembles  acute  melanchoha.  Attempts  at  suicide 
are  not  uncommon,  but  these  patients  frequently  lack 
resolve. 

(3)  The  demented  /orm.— Progressive  dementia  is  by  far 
the  most  common  type  of  mental  disorder  met  with  in  general 
paralysis.  Weak-mindedness  is  observed  at  some  stage  in  all 
types  of  dementia  paralytica,  but  in  this  variety  of  the  disease 
the  mental  enfeeblement  is  the  chief  characteristic  from  the 
beginning.  The  onset  is  usually  gradual  and  may  be  mis- 
taken for  neurasthenia.  The  memory  is  markedly  defective 
for  recent  events,  and  the  patients  are  constantly  making 
mistakes  in  work  that  they  could  formerly  do  with  accuracy. 
These  cases  are  frequently  wrongly  diagnosed.  Within  a  few 
weeks  more  alarming  symptoms  may  develop,  and  the  patient 
may  shock  public  decency.  He  may  show  irritabiHty,  and  from 
time  to  time  there  may  be  outbursts  of  passion  or  excitement. 
Delusions  of  an  exalted  kind  may  now  and  then  be  expressed, 
but  they  do  not  form  a  noticeable  feature  of  the  condition. 
These  patients  are  usually  very  tractable  and  are  easily 
treated  so  far  as  the  mental  aspect  of  the  malady  is  concerned. 
They  will  drop  off  to  sleep  during  meals  or  when  doing  work. 


230  PSYCHOLOGICAL  MEDICINE 

Ultimately    they    become    absolutely    childish    and    sit    mi- 
occupied  throughout  the  day. 

(4)  The  sfinal  form  of  general  paralysis  is  that  type  of 
the  disease  in  which  the  spinal  cord  is  first  affected.  The 
early  symptoms  are  those  of  locomotor  ataxy,  but  the  pro- 
gress of  the  malady  is  more  rapid  than  is  usually  the  case  in 
tabes  dorsalis,  and  within  a  few  months  mental  symptoms 
develop.  Eetention  of  urine  or  incontinence  are  frequently 
quite  early  sj^mptoms  in  this  type  of  general  paralysis. 

(5)  More  rarely  we  meet  with  delusional  forms  of  mental 
disorder  associated  with  general  paralysis.  These  persons 
beheve  that  they  are  the  victims  of  some  cruel  conspiracy  and 
state  that  they  are  amioyed  by  a  system  of  persecution.  Within 
a  comparatively  few  months  the  delusions  become  less  acute 
and  with  increasing  mental  failure  may  disappear  altogether. 

(6)  Stuporose  states  occasionally  occur  but  do  not  caU  for 
any  special  mention. 

In  describing  the  above  forms,  it  is  not  intended  that  the 
student  should  conclude  that  there  are  not  other  mental  types 
of  the  disease.  Occasionally  a  case  may  be  seen  wliich  does 
not  readily  fall  under  anj  of  the  above  headings,  or  the 
mental  state  may  be  an  alternating  one.  When  a  certain 
group  of  symptoms  is  predominant  a  case  may  be  classified 
in  a  subdivision  such  as  dementia  or  melanchoHa,  and  this  is 
convenient  in  many  ways,  especially  as  regards  the  prognosis 
and  treatment.  For  example,  the  depressed  types  usually  run 
a  longer  course  than  the  excited  forms  ;  whereas,  on  the  other 
hand,  remissions  are  more  frequent  in  the  latter. 

To  conclude  :  whatever  type  the  mental  disorder  assumes 
in  the  earlier  stages  of  the  disease,  the  final  stage  is  one  of 
profound  dementia.  Attribute  after  attribute  disappears  until 
there  is  nothing  left  of  the  former  intellect.  Mental  powers 
which  may  have  been  brilUant  are  now  obhterated,  and  the  man 
becomes  little  more  than  an  organism  capable  of  assimilating 
food.  But  the  physical  decay  follows  closely  on  the  mental, 
and  within  a  measured  time  the  organic  f mictions  upon  Avhich 
hfe  depends  fail,  and  the  man  dies.  Perhaps  it  is  this  order  of 
things  that  makes  general  paralysis  such  a  painful  disease  ior 
the  relatives  to  watch.  For  the  malady  begins  by  destroying 
the  whole  character  of  the  man  ;    it  robs  all  that  is  best,  and 


GENERAL  PARALYSIS  OP  THE  INSANE  231 

often,  for  a  time  at  least,  it  leaves  the  animal  instincts  to  run 
riot.  No  disease  exposes  the  scaffolding  upon  which  man  is 
built  in  all  its  bareness  in  such  a  way  as  general  paralysis  ; 
mortal  malady  that  it  is,  it  were  better  that  it  killed  outright  ; 
but  it  maims,  it  lowers  man  almost  to  the  level  of  the  brute 
creation  ;  and  then,  having  done  its  worst  upon  the  higher 
attributes,  it  attacks  the  vital  functions. 

Physical  Symptoms. — Next  let  us  consider  the  physical 
symptoms,  which  are  of  extreme  importance  in  general 
paralysis  ;  for  it  is  by  them  alone  that  the  diagnosis  can  be 
made.  Like  the  psychical,  they  are  numerous  and  varied. 
The  physical  signs  may  appear  before  the  mental  disturbances, 
or  vice  versa.  It  will  be  most  convenient  to  describe  each 
symptom  in  detail. 

Oculo-Motor  Symptoms. — Ptosis  and  strabismus  may  occur, 
but  are  not  common.  Nystagmus  is  seen  in  a  few  cases, 
but  the  chief  defects  are  connected  with  the  pupils.  The  size  of 
the  pupil  varies  from  extreme  mydriasis  to  myosis,  the  latter 
being  usually  the  condition  in  the  tabetic  forms  of  general 
paralysis.  Mydriasis  is  common  in  the  later  stages  of  the 
disease.  Irregularity  of  the  outline  of  the  pupil  may  be  of 
importance  but  as  a  rule  is  due  to  posterior  synechise. 
Irregularity  in  the  size  of  the  two  pupils  should  also  be  noted, 
but  it  must  not  be  forgotten  that  inequality  is  frequently  met 
with  in  healthy  persons,  or  it  may  be  caused  by  some  irrita- 
tion of  the  cervical  sympathetic.  Some  authorities  lay  stress 
upon  the  flattened  appearance  of  the  pupil.  It  is  the  failure 
of  the  reflex  adjustments  that  is  so  characteristic  of  general 
paralysis.  Upon  exposure  to  light  the  healthy  pupil  should  con- 
tract and  this  contraction  is  the  result  of  a  reflex  action. 

Eeflex  iridoplegia,  or  Argyll-Eobertson  pupil,  is  of  great 
significance,  and  a  symptom  of  the  utmost  importance  in 
making  a  diagnosis.  Some  authorities  consider  that  an 
Argyll-Eobertson  pupil  is  purely  a  parasyphilitic  symptom 
and  connotes  a  former  attack  of  syphilis.  Others,  probably 
rightly,  attach  much  greater  importance  to  the  phenomenon 
and  regard  it  as  pathognomonic  of  some  serious  disease, 
such  as  tabes  dorsalis  or  dementia  paralytica.  This  loss 
of  light  reflex  is  commonly  an  early  symptom  in  general 
paralysis,  but  it  is  always  present  when  the  disease  is  at  all 


232  PSYCHOLOGICAL  MEDICINE 

advanced.  The  loss  of  the  consensual  reflex  may  also  be 
noted  and  frequently  appears  among  the  earlier  symptoms. 
The  consensual  reflex  is  tested  by  alternately  covering  and 
exposing  one  eye  ;  in  the  healthy  subjects  when  one  eye  is 
shaded  the  pupil  of  the  exposed  eye  dilates.  With  the 
Argyll-Eobertson  pupil  the  reaction  during  convergence  is 
usually  normal.  Accommodative  adjustments  may  be  dis- 
turbed in  general  paralysis,  but  complete  failure  of  the 
pupil  to  contract  during  convergence  is  not  commonly  met 
^Yith  until  quite  late  in  the  disease,  and  even  then  it  is  the 
exception  rather  than  the  rule.  There  is  another  pupillary 
reflex  known  as  the  sym'pathetic  reflex,  which  may  be  affected 
in  dementia  paraMica.  Normally,  when  the  skin  of  the  neck 
is  pinched  or  stimulated  in  other  ways  the  pupils  dilate  ;  in 
general  paralysis  this  reflex  may  be  absent.  Primary  optic 
atrophy  may  be  occasionally  found  in  this  disease,  but  it  is  not 
common,  and  when  it  occurs  it  is  usually  in  the  tabetic  form. 

Speech  Defects. — The   articulatory   defects   are   among  the 
earlier  symptoms,  and  anyone  acquainted  with  the  speech  in 
dementia  paralytica  can  almost  make  a  diagnosis  from  it  alone. 
In  its  characteristic  form  the  speech  is  indistinct  and  drawled  ; 
there  is  a  clipping  of  the  last  syllables  of  words,  which  causes 
the  slm-ring  so  commonly  noticeable.     The  patient  frequently 
stops  and  has  difficulty  in  articulating  words,  and  during  these 
pauses  there  is  marked  tremor  and  over-action  of  the  facial 
muscles.     The  chief  difficulty  is  in  uttering  the  Unguals  and 
labials,  and  at  times  the  speech  closely  resembles  that  of  a 
drunken  man.     Many  patients  fully  appreciate  the  difficulty 
they   have   in   speaking,    and   will   explain  their   defects   by 
reference  to  their  artificial  teeth  not  fitting  properly.     Some 
general  paralytics  will  not  try  to  talk,  as  they  evidently  find 
difficulty  in  articulating.     Test-words,  such  as  the  following, 
may  be  tried,  but  as  a  general  rule  it  is  when  the  patient  is 
conversing  that  the  speech  is  heard  to  the  best  advantage  : 
'  Biblical  commentator  '  ;  '  The  Irish  constabulary  extinguished 
the  conflagration ' ;   '  immovability  '  ;  '  artillery.'     The  defects 
of  articulation  may  always  be  present,  but  they  are  usually 
more  marked  immediately  after  a  convulsive  seizure.     Tem- 
porary aphasia  is  not  uncommon   and    may  be  one  of    the 
earliest  symptoms  for  which  the  patient  consults  a  physician. 


GENERAL  PARALYSIS  OF  THE  INSANE  233 

In  the  later  stages  the  speech  may  be  so  slurred  and  run 
together  that  it  is  absolutely  unintelligible. 

Handwriting. — The  handwriting  may  be  affected  in  the 
early  stages  of  the  disease  ;  it  is  one  of  the  finer  muscular 
adjustments  and  is  of  late  development,  and  therefore  in 
dissolution  soon  loses  its  highly  acquired  characteristics. 
The  defects  in  the  handwriting  in  many  ways  resemble  those 
of  speech  ;  the  words  are  frequently  clipped  and  the  endings 
are  left  out,  or  words  or  syllables  may  be  reduplicated.  The 
writing  also  shows  muscular  failure.  The  fine  upstrokes  are 
tremulous  and  heavy  ;  letters  are  separate  and  uncertainly 
formed.  If  the  patient  uses  ink  the  paper  is  usually  covered 
with  smudges  and  blots  and  the  writing  sprawls  all  over  the 
page.  As  the  disease  advances  the  writing  becomes  thicker, 
and  the  difference  between  the  fineness  of  the  up  and  down 
strokes  is  entirely  lost.  In  later  stages  the  weight  of  the 
hand  on  the  paper  necessitates  the  use  of  a  pencil  in  the  place 
of  a  pen,  and  finally  the  patient  is  totally  unable  to  write  at 
all ;  or  if  he  attempts  to,  merely  makes  hieroglyphics  and 
unintelligible  scrawls. 

Tremors. — Tremors  may  be  observed  in  various  regions  of 
the  body,  but  they  are  usually  first  noticeable  in  the  muscles 
of  the  face  and  tongue.  The  lower  part  of  the  face  is  most 
affected,  whereas  in  the  purely  alcoholic  the  tremor  is  more 
common  in  the  upper  part.  The  face  shows  marked  loss  of 
expression,  and  all  the  original  lines  are  smoothed  and 
obliterated  as  the  result  of  the  loss  of  general  muscular  tone. 
This  smooth  expressionless  face  is  very  characteristic  of  the 
disease,  and  in  addition  there  is  usually  a  greasy  appearance 
of  the  skin.  When  the  patient  tries  to  speak  or  raise  his 
upper  lip,  tremor  appears  in  the  facial  muscles  and  there  is 
twitching  in  the  muscles  of  the  brow.  The  tongue  at  first 
shows  a  fine  tremor,  later  a  much  coarser  tremor,  and  it  is 
protruded  with  ataxic  convulsive  jerks.  Sucking  movements 
of  the  lips  are  common,  and  in  the  later  stages  there  may  be 
grinding  of  the  teeth. 

Gait. — The  gait  varies  according  to  the  type  of  the  disease. 
In  the  tabetic  form  the  gait  is  commonly  ataxic  from  the  first, 
and  the  unsteadiness  may  be  observed  for  some  time  before 
other    symptoms    appear.     In    these    cases    the    Ehomberg 


234  PSYCHOLOGICAL  MEDICINE 

symptom  is  usually  present.  In  the  majority  of  patients  with 
general  paralysis  the  gait  is  normal  during  the  initial  stages, 
but,  after  a  few  months,  unsteadiness  is  noticed  when  the 
.patient  attempts  to  turn  suddenly.  Later  the  movements 
become  slow  and  shuffling,  the  legs  are  separated,  and  the 
body  is  bent  and  sways  about  when  the  patient  tries  to  walk. 
Finally,  he  is  totally  unable  to  walk,  even  with  assistance  ;  for, 
as  the  name  indicates,  there  is  progressive  weakening  of  all 
the  muscles  of  the  body. 

Knee-jerhs.- — The  knee-jerks  may  be  exaggerated,  dimin- 
ished, absent,  or  unequal  on  the  two  sides.  The  exaggerated 
knee-jerk  is  the  most  common,  and  may  be  a  symptom  through- 
out the  illness,  or  after  a  few  months  may  become  diminished 
or  lost  altogether.  Exaggerated  knee-jerks  may  be  found 
in  many  persons,  notably  those  suffering  from  neurasthenia 
and  fatigue-states,  and  too  much  importance  must  not  be 
attached  to  the  symptom  if  it  is  not  associated  with  other 
indications  of  organic  disease.  In  the  tabetic  form  of  general 
paralysis  the  knee-jerks  are  absent. 

Beflexes. — In  the  depressed  cases  the  superficial  reflexes 
are  usually  absent  or  greatly  diminished.  The  plantar  reflex 
is  commonly  flexor  except  after  a  seizure,  when  it  may  be 
extensor  for  a  few  hours. 

Seizures. — Convulsive  or  paralytic  seizures  are  very  com- 
mon in  dementia  paralytica.  The  most  common  seizures 
are  :  (a)  eyileytiform  ;  (b)  a'poflectiform  ;  (c)  siiji-ple  faralytic 
or  syncofol  attacks.  In  addition  to  these,  and  more  especially 
in  the  early  stages  of  the  illness,  the  patient  may  suffer  from 
transitory  attacks  of  aphasia,  deafness,  or  blindness,  which  last 
from  five  minutes  to  a  quarter  of  an  hour,  and  when  they  occur 
they  are  very  characteristic  of  the  malady.  They  are  not  un- 
commonly quite  one  of  the  earliest  symptoms  which  attract 
notice. 

(a)  EfileiJiiform  Seizures. — In  many  ways  when  fully 
developed  these  seizures  are  almost  identical  with  those  of 
epilepsy.  There  is  no  cry  and  the  onset  is  not  quite  so  sudden. 
It  is  the  most  frequent  form  of  fit  but  varies  greatly  in 
.  severity  and  extent.  The  convulsive  twitching  may  be  hmited 
to  one  side  of  the  body,  or  it  may  be  bilateral.  There  may  be, 
and  usually  is,  loss  of  consciousness  ;   but,  on  the  other  hand. 


GENERAL  PARALYSIS  OF  THE  INSANE  235 

the  patient  may  retain  consciousness  throughout  the  seizure. 
Fits  may  occm*  singly  or  in  series,  and  if  several  take  place 
in  sequence  the  patient  may  regain  consciousness  between  the 
seizures  or  remain  in  an  imconscious  state  throughout.  In 
the  latter  case  the  fits  may  follow  each  other  so  rapidly  that 
the  condition  is  one  of  status  epilepticus,  and  while  in  this 
state  over  a  hmidred  fits  may  be  registered.  The  fit  may 
begin  in  one  hmb  and  rapidly  extend  over  the  body,  the  eyes 
and  head  deviate  to  one  side,  and  the  pupils  are  usually  dilated. 
The  tonic  stage  lasts  for  about  thirty  seconds  and  is  at  once 
followed  by  the  clonic  spasms,  which  may  continue  for  some 
time.  In  some  cases  the  tonic  stage  seems  to  be  absent  and 
the  fit  is  confined  to  twitching.  There  is  a  transient  hemianopia 
after  the  seizure  has  passed  off,  and  some  patients  are  aphasic 
or  show  hemiparesis  ;    but  all  these  symptoms  are  temporary. 

{h)  A'po'plectiform  Seizures. — Apoplectiform  seizures  are  not 
so  common  as  the  epileptoid.  In  these  attacks  the  face  is 
flushed  and  the  patient  passes  into  a  condition  of  coma.  The 
temperature  is  often  raised  ;  the  breathing  may  be  stertorous. 
In  some  cases  there  is  no  complete  loss  of  consciousness,  but 
merely  a  profound  state  of  lethargy  with  paresis  of  muscles  of 
one  or  both  sides  of  the  body.  Following  the  apoplectiform 
seizures  there  may  be  weakness  in  some  of  the  hmbs,  but  the 
paralysis  rapidly  passes  off ;  outbursts  of  mental  excitement 
occasionally  occm^  as  sequelge  of  these  '  congestive  '  attacks. 

(c)  Simple  Paralytic  Attacks. — Simple  general  muscular 
failure  may  take  place  without  any  preceding  convulsion.  A 
patient  may  suddenly  lose  muscular  power  and  fall  off  the 
chair  on  which  he  was  sitting.  There  is  no  loss  of  conscious- 
ness, but  merely  a  muscular  collapse.  These  attacks  are 
frequently  looked  upon  as  shght  attacks  of  syncope,  but  in 
reality  they  are  nervous  in  origin  and  not  cardiac. 

Temperature. — The  temperature  of  the  body  should  always 
be  taken  in  all  cases  of  general  paralysis,  as  frequently  it  is  a 
useful  index  of  approaching  trouble.  There  is  not  micommonly 
a  rise  of  temperature  a  few  hours  before  a  '  seizure.'  There 
may  be  hyperpyrexia  after  a  series  of  epileptiform  fits  or 
following  an  apoplectiform  attack.  The  temperature  may 
vary  on  different  sides  of  the  body  and  is  usually  higher  on 
the  paralysed  side.     A  rise  of  temperature  in  general  paralysis 


236  PSYCHOLOGICAL  MEDICINE 

may  be  the  only  indication  of  the  onset  of  some  intercmTent 
malady  such  as  pneumonia. 

Disorders  of  the  Muscular  Sense. — The  muscular  sense  is 
frequently  very  defecti^'e  in  dementia  paralytica.  Not  only  is 
the  patient  imcertain  in  his  power  of  locaHsation  and  in  gauging 
the  amomit  of  movement,  but  he  frequently  has  disordered 
sensations  "which  lead  him  to  beHeve  that  he  can  '  fly  '  or 
'  hft  enormous  weights.' 

Disorders  of  Sensation. — Sensation  is  not  ahvays  disordered 
to  any  great  extent  in  the  early  stages  of  the  illness.  Where 
alcohol  hab  been  a  prominent  factor  in  the  causation,  disorders 
of  sensation  are  common,  and  this  is  also  the  case  in  many  of 
the  patients  with  tabetic  symptoms.  In  the  later  stages 
sensation  is  usually  very  defective,  and  a  patient  has  been 
knoTMi  to  hold  his  hand  in  the  fire  mthout  suffering  any  acute 
pain.  The  loss  of  sensation  is  also  shown  in  those  patients 
who  may  have  severe  retention  and  yet  complain  but  little  of 
the  discomfort  felt  owing  to  the  distended  state  of  the  bladder. 
Further,  patients  ^\dll  leave  their  feet  against  a  hot-water 
bottle  until  severe  bmns  or  bhsters  result,  or  will  he  in  one 
position  for  a  long  time  until  bed-sores  form.  It  is  this  dis- 
order of  sensation  that  in  a  large  measure  makes  the  nursing 
of  general  paratytics  so  difficult,  as  the  nm-se  has  to  be 
ever  on  the  watch  to  prevent  accidents  happening.  The  dis- 
orders of  sensation  may  be  so  severe  that  the  patient  loses 
the  idea  of  his  own  identity  and  may  speak  of  himself  in  the 
third  person,  or  as  somethmg  else  altogether.  As  previously 
mentioned,  hallucinations  and  illusions  are  not  so  common  as 
in  some  other  forms  of  msanity,  but  they  are  present  in  about 
thirty-five  per  cent,  of  all  cases. 

Genito-urinary  SymiAoms. — -Sexual  desire  is  frequently 
excessive  in  the  earlier  period  of  the  disease,  but  sexual  power 
is,  as  a  rule,  lost.  In  the  initial  stages  there  may  be  retention 
or  incontinence  of  urine,  and  it  may  be  on  account  of  this 
difficulty  that  the  patient  first  consults  a  physician.  This 
condition  may  be  only  temporary  and  within  a  short  time  full 
control  is  regained.  Here  a  word  of  caution  to  the  unwary. 
In  these  cases  of  early  retention,  using  the  catheter  twice  a 
day  may  not  be  frequent  enough,  as  many  of  these  patients 
secrete  urine  at  a  very  rapid  rate,  and  within  a  few  hours 


GENERAL  PARALYSIS  OF. THE  INSANE  237 

several  pints  of  urine  may  collect  in  the  bladder.  In  the  later 
stages  of  the  disease  retention  may  be  a  trying  symptom, 
and  it  usually  is  accompanied  by  constant  dribbling,  which 
increases  the  difficulties  of  nursing  and  the  prevention  of 
bed-sores. 

Gastro-intestinal  Symytoms. — The  appetite  is  frequently 
excessive,  and  the  patient  is  inclined  to  '  bolt  '  his  food.  For 
this  reason  great  care  must  be  exercised  by  the  nurse  in  charge, 
as  the  patient  may  choke  himself,  especially  if  subject  to 
seizures.  In  the  later  stages  of  the  disease  minced  food  should 
always  be  ordered,  and  the  nurse  should  see  that  the 
patient  has  swallowed  one  mouthful  before  the  next  is  given. 
Vomiting  is  not  an  uncommon  symptom  in  dementia  paraly- 
tica ;  it  may  be  brought  about  by  the  patient  taking  some 
indigestible  food,  or  by  chewing  tobacco  or  leaves  from  the 
garden.  Some  general  paralytics  suffer  from  this  symptom 
periodically  ;  and  as  no  very  apparent  cause  can  be  discovered, 
it  must  be  looked  upon  as  nervous  in  origin.  Heematemesis 
is  occasionally  seen,  and  in  this  way  the  patient  may  lose 
large  quantities  of  blood.  The  bowels  are  frequently  con- 
stipated and  usually  require  very  regular  attention  throughout 
the  illness.  In  the  later  stages  all  power  over  the  sphincter 
ani  is  lost. 

Circulatory  Sym-ptoms. — In  the  earher  stages,  when  the 
symptoms  are  those  of  excitement,  the  pulse  is  usually  soft, 
low-tensioned,  and  frequent.  In  those  patients  who  are  de- 
pressed the  blood-pressure  is  raised  and  the  pulse  slow.  In  the 
later  periods  of  the  disease,  no  matter  of  what  type  the 
insanity  may  have  been,  the  blood-pressure  is  always  low- 
tensioned. 

Respiratory  Symptoms. — It  is  only  towards  the  termina- 
tion of  the  disease  that  the  respiratory  system  becomes  in- 
volved. Hypostatic  pneumonia  is  a  common  complication, 
and  in  many  cases  is  the  actual  cause  of  death. 

General  Nutritional  Changes. — In  the  earlier  periods  of 
the  illness  the  patient  not  uncommonly  loses  weight  ;  this  is 
especially  the  case  in  the  more  excited  forms  of  the  disease. 
Within  a  few  months  body  weight  begins  steadily  to  improve, 
and  the  patient  may  become  stout  and  at  times  unhealthily 
so.     Sooner  or  later  once  again  a  rapid  loss  of  weight  occurs, 


238  PSYCHOLOGICAL  MEDICINE 

and  as  months  pass  the  emaciation  becomes  very  marked. 
No  amount  of  nourishing  food  prevents  this  taking  place,  and 
the  progress  is  one  of  steady  nutritional  failure.  Trophic 
changes  take  place  in  all  the  tissues  of  the  body.  The  skin 
becomes  unhealthy-looking  and  pustules  or  small  superficial 
abscesses  may  form.  Herpes  zoster  is  not  uncommon.  The 
hair  and  nails  become  brittle.  The  bones  show  increased 
fragility  and  slight  injuries  may  cause  severe  fractures,  the 
ribs  being  very  liable  to  break.  Haematoma  auris  is  among 
the  more  common  trophic  changes  that  are  met  with  in  this 
disease..  In  the  final  stage  great  contraction  of  the  limbs 
usually  takes  place. 

Cerehro- spinal  Fluid. — If  the  cerebro -spinal  fluid  is  examined 
marked  changes  will  be  found  to  have  taken  place.  These 
will  be  described  later. 

Juvenile  General  Paxalysis. — General  paralysis  may  develop  in 
young  persons,  and  in  most  respects  it  follows  the  same  course 
as  it  does  in  the  adult.  Mott  has  made  a  full  examination  of 
twenty  cases  with  sixteen  autopsies,  the  account  of  which 
will  be  found  in  Volume  I.  of  the  '  Archives  of  Neurology.' 
He  states  that  the  average  age  of  onset  is  seventeen  years, 
the  female  being  attacked  somewhat  later  than  the  male.  A 
history  of  hereditary  syphilis  is  to  be  obtained  in  the  great 
majority  of  cases  ;  and  if  this  is  not  always  possible,  usually 
clinical  symptoms  of  congenital  syphilis  are  to  be  discovered 
in  the  patient  ;  also  the  patient  gives  a  positive  Wassermann. 
Some  authorities  state  that  a  neuropathic  inheritance  is  also 
an  important  getiological  factor.  Cases  are  recorded  in  which 
the  father  of  the  patient  had  general  paralysis.  Juvenile 
general  paralysis  runs  a  more  rapid  course  in  the  male  than  in 
the  female.  Puberty  and  head-injury  are  the  most  frequent 
exciting  causes.  In  some  cases  the  sexual  organs  are  not  fully 
developed.  The  catamenial  periods  may  never  have  appeared, 
but  if  they  have  done  so  they  immediately  cease  when  the 
illness  begins.  Many  of  these  patients  will  be  found  to  have 
exhibited  signs  of  mental  weakness  for  some  years  prior  to 
the  full  development  of  the  paralytic  symptoms,  and  may 
never  have  been  capable  of  doing  work.  Progressive  de- 
mentia is  the" most  common'type  of  mental  disorder  occurring 
in    juvenile    general    paralysis.     Delusions    of    grandeur    are 


GENERAL  PARALYSIS  OF  THE  INSANE  239 

decidedly  rare.  The  ordinary  physical  symptoms  such  as 
tremors  of  face  and  tongue,  slurred  speech,  pupillary  changes, 
handwriting,  affections,  etc.,  can  usually  be  observed.  Con- 
vulsive seizures  are  not  common,  and  when  they  do  occur  are 
usually  mild  in  character.  The  morbid  anatomy  changes  are 
similar  to  those  which  are  found  in  the  adult. 

Course. — General  paralysis  has  been  divided  up  into  three 
stages,  but  although  this  arrangement  may  be  convenient  for 
the  student,  it  is  nevertheless  at  times  confusing  in  the  actual 
clinical  observation  of  the  disease.  For  example,  it  is  not 
uncommon  to  find  a  patient  rapidly  pass  through  the  first  and 
second  stages,  and  even  apparently  reach  the  third  and  final 
stage,  and  then  improve  and  return  to  the  first  stage,  or  have 
a  complete  remission. 

Notwithstanding  this  difficulty,  there  is  much  to  be  said 
in  favour  of  retaining  the  system  of  division  into  the  three 
stages,  as  it  is  certainly  helpful  to  those  first  studying  the 
disease,  (a)  The  first  period  is  that  of  slight  inco-ordination 
and  failure  of  the  finer  muscular  adjustments,  such  as  speech 
and  handwriting,  slight  tremors,  and  mental  failure,  which  is 
usually  accompanied  by  exaltation,  excitement,  or  depression. 
[h)  The  second  period  is  that  of  greater  muscular  inco-ordina- 
tion, with  a  tendency  to  become  fat  and  gross,  with  a  greater 
liability  to  seizures,  and  more  advanced  mental  deterioration, 
(c)  The  third  period  is  that  of  extreme  muscular  failure,  with 
tendency  to  contractions,  progressive  emaciation,  loss  of 
power  over  all  sphincters,  and  mentally  a  condition  of  profound 
dementia.  Thus  it  will  be  seen  that  the  course  of  general 
paralysis  is  one  of  steady  and  progressive  mental  and  physical 
deterioration.  Although  this  is  ultimately  the  true  course  of 
events  in  a  fair  proportion  of  cases,  the  progress  of  the  disease 
appears  to  stop  for  a  time,  this  improvement  varying  from  a 
few  weeks  to  several  months.  During  this  period  of  quiescence 
the  patient  may  enjoy  apparent  health,  and  the  term  remission 
has  been  used  to  connote  the  condition.  This  subject  will 
again  be  referred  to  in  a  subsequent  paragraph. 

The  course  of  general  paralysis  may  be  a  very  rapid  one, 
and  the  patient  may  die  within  a  few  months  of  the  establish- 
ment of  the  disease.  'I  More  commonly  the  course  is  a  longer 
one,   varying  from  two   and  a    half  to  four  years,  or  even 


240  PSYCHOLOGICAL  MEDICINE 

more.  The  cases  with  depression  usually  live  the  longest, 
and  the  course  is,  as  a  rule,  longer  in  women  than  in  men. 
Occasionally  a  general  paralytic  may  live  seven  years  or  even 
longer.  The  causes  of  death  vary  in  different  cases,  but  the 
following  are  the  most  frequent  :  (a)  Exhaustion,  (b)  status 
epilepticus,  (c)  pulmonary  disease,  {d)  cystitis  and  kidney 
disease,  (e)  heart  failure. 

Remission. — In  some  cases  of  dementia  paralytica  all 
symptoms,  both  mental  and  physical,  suddenly  begin  to  clear 
up  ;  the  improvement  may  be  rapid  or  steady,  or  may  be 
partial  or  complete.  As  a  rule  the  pupillary  symptoms  persist. 
The  general  paralytic  with  expansive  delirium  or  excitement 
is  more  likely  to  have  a  remission  than  the  depressed  or 
demented.  The  remission  usually  occurs  in  the  early  months 
of  the  disease  and  may  last  from  a  few  months  to  a  year,  or 
at  times  longer.  During  the  remission  the  patient  is  fre- 
quently capable  of  doing  work,  and  often  good  work.  Never- 
theless, his  acquaintances  usually  notice  that  the  man's 
character  is  altered  ;  he  may  be  more  facile  to  get  on  with, 
but  he  is  easily  fatigued  mentally.  Some  patients  are  inclined 
to  be  irritable,  or  extravagant  with  money.  It  is  very  im- 
portant to  warn  relatives  that  a  patient  with  general  paralysis 
may  have  a  remission,  otherwise,  when  it  takes  place,  they 
may  blame  the  physician  for  having  told  them  that  the  patient 
was  suffering  from  a  mortal  malady  and  for  having  led  them 
to  believe  that  he  would  not  be  fit  for  any  more  work.  It 
is  seldom  that  a  patient  has  more  than  one  remission  during 
the  course  of  his  illness. 

Diagnosis. — The  diagnosis  of  general  paralysis  must  be  made 
almost  entirely  from  the  physical  symptoms.  Pupillary  defects, 
disorders  of  speech,  tremors,  seizures,  etc.,  are  the  symptoms 
which  will  assist  most  in  making  an  accurate  diagnosis. 
Eapid  failure  of  memory  and  marked  change  of  character, 
with  tendency  to  extravagance,  etc.,  in  a  man  between  thirty 
and  forty-five  may  suggest  dementia  paralytica,  but  unless 
some  physical  signs  of  the  disease  are  to  be  discovered  the  final 
decision  must  be  postponed  for  a  time.  The  examination  of 
the  cerebro-spinal  liuid  often  makes  the  diagnosis  clear.  The 
following  are  the  disorders  that  general  paralysis  is  apt  to 
be    confused  with  :    (a)  AlcohoHc    insanity,    (6)  neurasthenia, 


GENERAL  PARALYSIS  OF  THE  INSANE  241 

(c)  arterio-sclerosis,  (cl)  mania  or  melancholia,  (e)  chronic 
delusional  insanity,  (/)  syphiUtic  insanity,  {g)  cerebral  tumours, 
(h)  epilepsy,  (i)  locomotor  ataxy,  (7)  senile  dementia. 

(a)  The  differential  diagnosis  between  alcoholic  pseudo- 
paralysis and  dementia  paralytica  has  been  fully  described 
in  the  chapter  on  Alcoholism,  and  the  reader  is  asked  to 
refer  to  Avhat  has  been  already  written  on  this  difficult  and 
important  subject. 

(fo)  The  symptoms  in  neurasthenia  may  closely  resemble 
some  of  the  early  symptoms  of  general  paralysis.  The  neu- 
rasthenic may  hesitate  in  his  speech  when  nervous,  and  there 
may  be  tremor  of  the  facial  muscles  when  speaking  ;  but  he 
is  usually  aware  of  his  condition  and  is  constantly  trying  to 
get  relief,  whereas  the  general  paralytic  does  not  realise  that 
he  is  ill.  Seizures,  or  Argyll-Kobertson  pupil,  strongly  favour 
general  paralysis,  and  the  latter  are  never  present  in  neu- 
rasthenia. Further,  the  neurasthenic  does  not  lose  his  moral 
sense  and  his  memory  is  never  seriously  defective.  A  positive 
Wassermann  and  a  lymphocytosis  in  cerebro-spinal  fluid  are 
almost  conclusive  of  general  paralysis. 

(c)  In  arterio-sclerosis  the  patient  is  usually  over  fifty. 
He  is,  as  a  rule,  conscious  of  his  loss  of  memory,  and  he  may 
have  some  coarse  paralyses.  Here  again  lumbar  puncture  may 
greatly  help  in  making  a  right  diagnosis. 

(d)  It  is  frequently  necessary  to  distinguish  between  general 
paralysis  and  mental  disorders  such  as  mania  and  melancholia. 
No  absolute  diagnosis  can  be  made  until  the  physical  signs  of 
organic  disease  appear.  The  excitement  of  ordinary  mania  is 
not  so  unreasoning  as  that  of  general  paralysis.  The  mental 
deterioration  is  greater  in  the  latter  disease.  In  mania  and 
melancholia  the  memory  is  never  really  bad,  as  it  may  be 
in  dementia  paralytica,  and  hallucinations  are  more  common 
in  these  disorders.  Speech  defects,  and  failure  of  muscular 
power,  altered  handwriting,  pupillary  changes,  and  seizures 
all  point  to  general  paralysis,  and  the  blood  and  the  cerebro- 
spinal fluid  should  be  examined. 

(e)  In  chronic  delusional  insanity  the  onset  is  very  gradual, 
and  its  course  is  a  slow  one ;  delusions  of  grandeur  are 
usually  of  late  development.  The  delusions  gradually  become 
organised,  and  there  is  a  total  absence  of  any  physical  signs 

16 


242  PSYCHOLOGICAL  MEDICINE 

of  organic  disease.  Hallucinations  are  more  common  in  the 
true  delusional  state. 

if)  Syphilitic  insanity,  the  result  of  syphiUtic  disease  of  the 
brain,  is  often  very  difficult  to  distinguish  from  general  paralysis. 
Local  paralyses  favour  syphilitic  insanity.  In  the  latter  disease 
a  third  nerve  palsy  is  common,  and  headaches  are  usually 
very  severe  and  are  worse  at  night.  Optic  neuritis  would 
pomt  to  syphilitic  disease,  as  it  is  not  common  in  general 
paralysis.  An  Argyll-Eobertson  pupil  is  of  less  value  as  a 
diagnostic  sign,  for  it  occurs  in  both  diseases.  Tremors  are 
seldom  present  in  syphilitic  insanity.  Speech-defects  favour 
general  paralysis,  as  aphasic  states  are  the  only  form  of  speech- 
disorders  met  with  in  syphilitic  insanity.  The  mental  state 
of  the  sypliihtic  patient  is  usually  one  of  depression  with  a 
tendency  to  become  gradually  weak-minded.  The  important 
point  to  remember  is,  that  with  antisyphilitic  treatment  the 
patient  with  sypliihtic  insanity  often  rapidly  improves,  whereas 
such  treatment  is  valueless  in  general  paralysis.  In  the  case 
of  general  paralysis  the  progress  of  the  disease  is  usually  one  of 
steady  deterioration,  and  one  remission  is  the  most  that  can  be 
looked  for.  The  cerebro-spinal  fluid  should  be  carefully  examined. 

{g)  Cerebral  tumours  in  some  cases  may  resemble  general 
paralysis,  but,  as  a  general  rule,  the  differential  diagnosis  is  not 
difficult.  The  mental  symptoms  are  usually  of  late  develop- 
ment in  intra-cranial  tumom's,  and  the  localising  symptoms 
of  the  latter  generally  precede  them.  Optic  neuritis,  intense 
headache,  and  vomiting  strongly  favour  tumour.  The  mental 
state  of  the  patient  with  cerebral  tumour  is  that  of  pro- 
gressive dementia  with  marked  loss  of  memory.  The  usual 
physical  signs  of  general  paralysis  are  mostly  absent,  and 
the  examination  of  the  blood  and  cerebro-spinal  fluid  give 
negative  results. 

(h)  It  is  very  rare  for  true  epilepsy  to  begin  after  the  age 
of  thirty  yeai-s,  and  there  ought  to  be  no  difficulty  in 
distinguishing  this  malady  from  general  paralysis,  as  the 
history  and  symptoms  of  the  two  diseases  differ  greatly. 

(i)  A  patient  with  tabes  dorsahs  may  ultimately  develop 
general  paralysis.  In  fact,  authorities  are  now  agreed  that 
they  are  the  same  disease,  in  one  case  the  brain  being  affected 
and  in  the  other  the  spinal  cord.     Therefore  it  is  often  very 


GENERAL  PARALYSIS  OF  THE  INSANE  243 

difficult  to  decide  whether  the  case  is  a  true  tabes  paralysis, 
or  merely  tabes  dorsahs  with  nerve  exhaustion  or  other 
mental  symptoms.  Clearly  the  examination  of  the  blood 
and  the  cerebro-spinal  fluid  are  not  always  helpful,  but  Mott 
states  that  an  abundant  lymphocytosis  and  a  marked  positive 
Wassermann  reaction  of  the  cerebro-spinal  fluid  strongly  favours 
the  diagnosis  of  general  paralysis,  especially  if  associated  with 
epileptiform  seizures.  Mott  states  that  ten  per  cent,  of  the 
cases  of  tabes  end  in  extension  of  the  disease  to  the  brain. 

(j)  When  general  paralysis  appears  late  in  life,  it  may  be 
necessary  to  diagnose  it  from  senile  dementia,  especially  when 
this  latter  condition  is  associated  with  any  paralysis  or  speech- 
defect.  The  course  of  senile  dementia  is  slower,  and  there  are 
usually  no  pupillary  changes  ;  and  further,  if  there  is  any  weak- 
ness, it  is  a  localised  weakness.  The  changes  in  speech  are 
different  in  the  two  diseases,  for  in  senile  dementia  the  patient 
is  either  permanently  aphasic,  or  the  speech  is  merely  blurred 
and  thickened  and  quite  distinct  from  the  slurred  tremulous 
articulations  of  the  general  paralytic.  To  conclude :  the 
diagnosis  of  dementia  paralytica  is  often  overlooked  in  the 
early  stages  of  the  disease,  because  physicians  do  not  examine 
the  patient  carefully  enough  for  physical  signs  and  too  fre- 
quently make  their  diagnosis  from  the  mental  symptoms 
alone.  Dementia  paralytica  is  so  common  a  malady  that  the 
possibility  of  its  being  present  ought  always  to  be  considered 
in  every  case  of  insanity,  no  matter  what  the  type  of  mental 
disorder  may  be. 

Prognosis. — The  prognosis  is  as  a  rule  hopeless,  and  most 
patients  die  within  three  years  from  the  time  that  the  disease 
becomes  estabhshed.  A  remission  may  occur,  but  it  is  only  a 
temporary  improvement.  In  some  cases  the  disease  lasts  for 
seven  years,  or  with  treatment  it  has  been  known  to  remit 
for  longer. 

Pathology  and  Pathological  Anatomy.— The  pathology  of 
general  paralysis  is  a  subject  which  has  received  great 
attention  during  recent  years.  We  have  already  pointed  out 
that  syphiHs  is  now  proved  to  be  the  most  important  factor. 
Authorities  have  long  disagreed  as  to  the  actual  nature  of 
the  disease.  Some  have  regarded  it  as  primarily  a  chronic 
inflammatory    change     either    of    the    meninges    or    cortical 


244  PSYCHOLOGICAL  MEDICINE 

structures,  and  for  this  reason  the  term  chronic  meningo- 
ence-pJialiiis  has  been  given  to  the  malady.  Some  state  that 
the  condition  is  primarily  a  degeneration  of  the  neuron  and 
that  all  other  changes  are  secondar3^  Others  hold  that 
the  initial  changes  take  place  in  the  interstitial  tissues  of 
the  brain  and  that  it  is  only  in  the  later  stages  of  the  disease 
that  the  nervous  elements  become  affected.  Others  believe 
that  it  is  the  cerebral  blood-vessels  which  are  primarily  diseased 
and  that  this  in  turn  leads  to  extensive  nutritional  alteration 
in  the  neuron  and  other  structures  suppHed  by  these  arterioles. 
Stoddart  lays  great  emphasis  upon  the  fact  that  as  the  parts 
of  the  nervous  system  which  suffer  most  are  those  which 
are  most  accessible  to  the  cerebro-spinal  fluid,  the  conclusion 
is  almost  irresistible  that  the  specific  toxin  of  general  paralysis 
is  to  be  found  in  this  fluid,  and  that  it  is  already  present  in 
it  when  the  fluid  is  secreted  from  the  choroid  plexuses. 

The  tendency  at  the  present  time  is  to  look  upon  it  as  a 
toxic  condition,  and  this  view  is  supported  by  the  fact  that, 
although  the  nervous  elements  are  the  structures  which  are 
most  severely  affected,  changes  take  place  in  all  the  tissues 
and  organs  of  the  body.  Thus  it  will  be  seen  that  at  different 
times  general  paralysis  has  been  regarded  as  a  primary  degene- 
ration or  inflammation  of  the  parenchymatous  or  an  inflam- 
mation of  the  interstitial  elements  of  the  brain,  a  primary 
inflammation  of  the  pia-arachnoid,  or  a  disease  of  the  blood- 
vessels. There  is  no  doubt  that  all  the  structures  of  the  brain 
finally  become  involved  in  the  disease,  but  it  is  by  no  means 
easy  to  locate  the  site  of  the  earliest  changes  or  to  indicate 
their  nature.  It  may  be  that  in  some  cases  they  appear  in 
the  parenchymatous  elements,  in  others  in  the  interstitial 
structures  or  blood-vessels,  and  that  this  accounts  for  the 
different  clinical  types  of  the  disease.  It  has  long  been  felt 
that  under  the  name  of  general  paralysis  we  probably  include 
other  diseases  which  closely  resemble  it,  and  in  time  we  hope 
to  be  able  to  differentiate  between  them.  By  the  process  of 
elimination  certain  pseudo-paralyses  have  already  been  with- 
drawn and  placed  in  other  groups  ;  no  doubt,  in  time,  others 
will  also  follow. 

Mott's  view  of  the  nature  of  para-syphilitic  disease  of  the 
nervous  system  is  as  follows  : 


GENERAL  PARALYSIS  OF  THE  INSANE  245 

'  Para-syphilitic  disease  of  the  nervous  system  depends  on 
two  factors — intrinsic,  innate,  and  extrinsic,  acquired — the 
soil  and  the  seed  ;    the  vital  resistance  and  the  specificity 

of  the  virus,   —      All  those    conditions,  which    may  be  in- 

herited  or  acquired,  and  which  tend  to  active  metabolism 
of  systems,  communities,  and  groups  of  neurons  functionally 
correlated,  and  which — owing  to  these  conditions  of  stress, 
which  in  one  individual  would  cause  spinal  neurasthenia,  in 
another  central  neurasthenia — will,  in  conjunction  with  the 
stimulating  effect  of  the  syphilitic  poison,  cause  the  nerve 
cells  to  exercise  an  abnormal  metabolic  activity  in  the  produc- 
tion of  the  side-chain  molecules  necessary  for  immunisation 
against  the  toxic  effects  of  the  virus. 

'  Ehrlich  points  out  that  we  cannot  suppose  that  the  cells 
of  the  body  possess,  'per  se,  an  executive  defensive  capacity  to 
neutralise  the  noxious  effects  of  all  forms  of  organisms,  and 
his  work  on  "Hsemolysins  "  shows  that  the  hsemolysin  for  the 
corpuscles  of  a  particular  animal  only  occurs  after  incor- 
poration of  the  molecules  of  those  corpuscles.  But  we  may 
suppose  that  there  is  an  inherent  aptitude  for  the  cells  of 
the  body  of  certain  individuals  to  readily  adapt  themselves 
to  defence  against  the  action  of  the  syphilitic  virus  in  a  race 
that  has  been  widely  syphilised  for  generations  ;  consequently 
a  larger  number  will  have  a  mild  form  of  the  disease. 

'  The  nerve  cells  are  p.erpetual  elements  incapable  of 
regeneration,  highly  differentiated  and  complex  in  structure 
and  function,  their  centre  of  nutrition  is  the  nucleus,  and 
when  decay  sets  in,  the  regressive  process  attacks  first  the 
fine  twigs  and  branches  of  the  tree,  the  dendrites  and  den- 
drons,  and  the  rootlets— in  fact,  the  process  is  an  inversion 
of  its  growth  and  development.  But  what  should  cause  this 
premature  decay  and  lack  of  durability  ?  For  the  specific 
energy  of  the  whole  of  the  neurons  in  the  healthy  body  is 
sufficient  to  last  until  the  vital  spark  dies  out. 

'  We  know  that  one  attack  of  syphilis  confers  immunity 
during  the  rest  of  the  individual's  life,  and  the  experiments 
of  Krafft-Ebing  are  important  to  remember  in  this  respect. 
The  nerve  elements  being  perpetual,  having  acquired  a  habit 
of  throwing  off  side-chain  molecules,  will  continue  to  do  so 


246  PSYCHOLOGICAL  MEDICINE 

during  life  and  will  contribute  largely  to  the  immunity  pro- 
duced. When  there  is  no  longer  metabolic  equilibrium,  and 
decay  sets  in,  these  immune  bodies  are  thrown  off  in  increasing 
numbers  ;  this  seems  probable  from  the  fact  that,  in  general 
paralysis  and  tabes,  the  quantities  increase  with  the  progress 
of  the  decay.  The  process  of  decay  will  manifest  itself  in 
the  earliest  stages  by  an  increased  irritability  and  functional 
activity  of  the  nervous  structures,  often  manifesting  itself 
in  a  hypergesthesia  sexualis,  and  not  infrequently  in  striking 
intellectual  activity,  followed  in  each  case  by  exhaustion  and 
loss  of  function. 

'  The  uselessness  of  antisyphiUtic  remedies  is  thus  easily 
accounted  for  ;  indeed,  they  are  generally  positively  injurious 
in  true  tabes  and  general  paralysis,  because  they  lower  the 
vital  energy  in  a  system  which  has  over-immunised  itself 
against  the  syphilitic  virus.  The  only  hope  of  doing  any  good 
is  by  an  early  diagnosis  of  the  disease  and  suppression  of  all 
those  exciting  causes  which  use  up  the  nervous  energy  and 
tend  to  overturn  the  metabolic  equilibrium  of  the  central 
nervous  system,  causing  its  premature  decay.  This  may 
explain  a  well-known  fact,  first  pointed  out  by  Benedikt, 
that  tabetic  patients  Avho  become  blmd  from  optic  atrophy 
remain  in  the  pre-ataxic  stage  a  great  number  of  years.  Neuro- 
j)otential,  or  nerve  energy,  is  for  the  most  part  used  up  in  mental 
processes  involving  attention.  The  loss  of  sight  necessitates 
mental  inactivity,  provided  the  ;^atient  does  not  worry.  My 
experience  is  that  these  cases  of  optic  atrophy  generally  either 
remain  in  the  pre-ataxic  stage  or  develop  general  paralysis. 
I  have  found  in  the  history  of  the  latter  great  mental  de- 
pression arising  from  loss  of  sight.  Possibly  some  remedy 
may  be  found  which  will  allay  this  hyper-nutritive  and 
metabolic  activity  of  the  nervous  system.  It  is,  in  my  opinion, 
a  fact  that  very  frequently  general  paralytics  and  tabetics  are 
mentally  and  physically  superior  to  the  average  individual 
who  belongs  to  the  same  social  status,  and  I  have  always 
considered  it  probable  that  the  frequent  indulgence  of  abnor- 
mally strong  sexual  desires  stimulated  by  many  causes, 
especially  alcohol,  is,  after  syphilis,  the  most  important 
factor  in  the  production  of  tabes  and  general  paralysis.  It 
acts    in    two    ways  :    (1)    directly    by    exhaustion    of   neuro- 


GENERAL  PARALYSIS  OF  THE  INSANE  247 

potential ;  (2)  indirectly  in  the  male  by  the  excessive  loss 
to  the  body  of  highly  phosphorised  nucleo-proteids  con- 
tained in  the  sperm.  These  are  biochemical  substances 
possessed  of  great  specific  energy,  and  are  not  easily 
replaced.' 

Macrosco'pic. — The  skull-cap  is  generally  thickened,  and 
the  diploe  is  obliterated.  The  dura  mater  is  thickened,  and 
more  or  less  extensively  adherent  to  the  calvarium.  A  blood- 
clot,  partially  or  wholly  organised,  may  be  found  on  the  under 
sm'face  ;  some  persons  look  upon  this  false  membrane  as  the 
result  of  heemorrhagic  pachymeningitis.  This  sub-dural  false 
membrane  is  usually  situated  on  the  vertex,  and  varies 
in  thickness  from  a  thin  rust-colojired  fibrinous  layer  to  a 
thick,  tough  membrane.  It  is  probably  produced  by  a 
degenerate  vessel  rupturing  ;  the  clot  which  is  thus  formed 
becomes  organised,  and  new  vessels  form  which  in  turn 
become  degenerate  and  rupture,  and  each  time  this  occurs 
a  new  layer  is  added  to  the  existing  membrane.  The 
Pacchionian  bodies  are  increased  in  size.  The  pia-arachnoid 
is  thickened  and  cedematous,  and  shows  scattered  milky 
opacities.  Pia  is  adherent  to  pia  between  the  hemispheres, 
but  not,  as  a  rule,  between  the  sulci.  The  pia-mater  is 
abnormally  vascular  and  is  adherent  to  the  convolutions, 
especially  in  the  frontal  and  parietal  regions.  "When  any 
attempt  is  made  to  strip  the  pia-arachnoid  from  the  surface 
of  the  brain,  a  lacerated  surface  is  often  left  at  the  summits 
of  the  convolutions.  This  condition  is  most  marked  in  those 
patients  who  die  in  the  earlier  stages,  whereas  in  the  later 
stage  the  pia-arachnoid  strips  almost  too  readily. 

The  convolutions  are  atrophied,  and  the  grey  matter  is 
thinned,  especially  in  the  frontal  and  parietal  regions,  and 
the  whole  brain  is  softened  ;  these  changes  show  themselves 
microscopically  in  tortuosity  of  the  radiations.  The  ventricles 
are  dilated.  The  ependym.a,  especially  of  the  fourth  ventricle 
and  the  walls  of  the  lateral  ventricles,  is  usually  studded  with 
granulations,  which  give  rise  to  the  frosted  appearances 
commonly  referred  to.  The  cerebro-spinal  fluid  is  always 
greatly  increased  in  quantity  and  is  somewhat  more  opaque 
than  normal. 

The  importance  of  the  presence  of  cholin  in  the  blood  has 


248  PSYCHOLOGICAL  MEDICINE 

lately  been  discussed.  Mott  suggested  that  it  may  be  the 
cause  of  the  fatty  degeneration  that  takes  place  in  the  various 
organs  of  the  body,  and  others  have  stated  that  it  may  be 
the  cause  of  the  epileptic  seizures  so  common  in  this  disease. 
It  would  thus  appear  that  the  causation  of  these  fits  must  be 
sought  for  in  some  other  direction  than  from  cholin. 

The  total  weight  of  the  brain  is  below  normal,  and  this 
reduction  may  be  very  marked  in  some  cases.  Foci  of  soften- 
ing may  be  found  scattered  about  and  are  especially  noticeable 
in  the  cortex.  There  is  also  increased  vascularity  throughout 
the  cortex  and  white  matter. 

Microsco'pic. — The  thickening  and  opaque  appearance  of 
the  pia-arachnoid  are  due  to  proliferation  and  degeneration 
of  the  endothelial  lining.  Bevan  Lewis  attributes  the  morbid 
adhesion  of  the  pia-arachnoid  to  the  cerebral  cortex  to  an 
overgrowth  of  neuroglia.  Ford  Eobertson  points  out  that 
there  are  two  factors  in  the  production  of  the  normal  degree 
of  adhesion  :  '  (a)  The  interlacement  and  attachment  of  the 
glia  fibres  to  the  connective  tissue  fibres  of  the  pia-arachnoid  ; 
and  (6)  the  blood-vessels  which  pass  from  the  membrane  into 
the  substance  of  the  brain.'  He  goes  on  to  say  that  '  there 
are  likewise  two  factors  in  the  production  of  an  abnormal 
degree  of  adhesion  of  the  pia-arachnoid  to  the  cortex  :  (a)  In- 
crease in  the  number  and  strength  of  the  glia  fibres  ;  and 
(b)  increase  of  the  connective  tissue  fibres  of  the  adventitia 
of  the  vessels.'  Ford  Eobertson  considers  that  it  is  the 
vascular  factor  which  is  the  important  one.  He  further  con- 
siders tlrnt  the  eroded  appearance  of  the  convolutions  observed 
after  the  stripping  off  of  the  pia-arachnoid  is  due  to  softening 
of  the  cortical  tissues,  and  in  support  of  this  idew  he  states 
that  *  if  a  normal  brain  is  allowed  to  soften  from  post-mortem 
change,  the  whole  membrane  (pia-arachnoid),  both  in  the 
sulci  and  over  the  convolutions,  strips  off  with  adhesion  and 
laceration  of  the  cortex,  just  as  occurs  near  the  top  of  the 
same  convolution  in  certain  cases  of  general  paralysis.' 

The  small  blood-vessels  are  numerous,  tortuous,  and  fre- 
quently distended  with  blood.  Their  coats  are  thickened  and 
show  hyaline,  fibroid,  or  fatty  degeneration.  There  is  over- 
gro\vth  of  the  endothelial  cells  of  the  capillaries,  and  on  their 
adventitial  sheath,  which  normally  consists  of  elongated  cells, 


GENERAL  PARALYSIS  OE  THE  INSANE  249 

there  develops  a  regular  felt-work  of  similar  cells  having  special 
characters  (plasma  cells).  They  have  a  clear  centre  and 
contain  minute  granules  which  stain  with  methylene  blue,  and 
the  nucleus  occupies  an  eccentric  position.  Stoddart  states 
that  the  resemblance  of  these  '  plasma-cells  '  to  normal  cells 
of  the  adventitial  sheath  is  very  striking  and  suggests  a  more 
probable  source  of  origin.  Some  authorities  regard  them  as 
altered  leucocytes,  and  others  as  derivatives  of  glia  cells.  The 
perivascular  lymph  spaces  are  dilated  and  are  filled  with  exuded 
leucocytes.  Mast-cells  are  also  to  be  observed  and  connective 
tissue  leucocytes  with  basophile  granules.  Endarteritis  obli- 
terans may  be  seen  in  some  of  the  vessels.  The  changes  in  the 
nerve-cells  vary  to  a  certain  extent,  according  to  whether  the 
disease  runs  a  rapid  or  slow  course.  In  the  former  condition 
a  greater  number  of  cells  show  marked  morbid  alteration  and 
there  is  less  sclerotic  change.  The  destruction  of  nerve-cells  fre- 
quently begins  in  the  large  cells  of  Betz  in  the  mid-Eolandic  area. 
The  following  are  the  most  common  changes  to  be  observed  : 
(a)  Chromatolysis — by  this  we  mean  the  breaking  up  of  the 
granules  which  form  the  Nissl  bodies — ^in  other  words,  the 
destruction  of  the  colouring  matter  of  the  cell.  Chromatolysis 
is  seen  in  many  forms  of  nervous  disorder  and  is  merely  indi- 
cative of  some  disturbance  of  nerve-cell  nutrition.  Omng  to 
this  destruction  of  Nissl  bodies  the  perinuclear  mass  (nerve- 
cell)  does  not  stain  so  well  as  normally,  (h)  Achromatolysis 
is  also  to  be  observed,  and  this  is  a  much  more  serious  condition. 
By  acliromatolysis  we  mean  that  the  fibrils  in  the  cell  itself 
have  become  degenerate  and  disintegrated,  (c)  The  nucleus 
of  the  cell  becomes  displaced,  and  is  frequently  found  lying 
against  the  periphery  of  the  cell- wall ;  this  displacement  is  prob- 
ably due  to  the  achromatic  disintegration  already  referred  to. 
The  nucleus  is  commonly  altered  in  shape,  is  often  triangular 
and  usually  stains  more  readily  than  normally,  (d)  The 
nerve-cells  at  times  show  fatty  degeneration,  (e)  Vacuola- 
tion  may  be  observed  either  in  the  cell  or  nucleus.  (/)  The 
nerve-cell  becomes  altered  in  contour  and  may  be  very  shrmiken 
in  appearance  or  even  disappear  altogether,  {g)  The  cell- 
processes  are  affected  in  a  similar  way  to  the  perinuclear  mass, 
and  the  cell  is  frequently  found  to  be  separated  from  its  process. 
There  is  degeneration  of  the  axis-cylinder,  breaking  up  of  the 


250  PSYCHOLOGICAL  MEDICINE 

myelin  sheath,  and  proliferation  of  nuclei  in  the  sheath  of 
Schwann.  The  dendrons  are  varicose  and  atrophied.  (Ii)  The 
tangential  fibres  of  the  cortex  undergo  varicosity  and  atrophy 
and  finally  disappear,  (i)  The  changes  in  the  connective  tissue 
elements  are  as  great  as  those  which  may  be  observed  in  the 
nervous  structures. 

With  the  disappearance  of  the  nerve-cells  there  is  an  in- 
crease in  the  neurogHa.  This  increase  may  be  apparent  rather 
than  real,  for  it  may  appear  relatively  greater  owing  to  the 
absolute  deficiency  of  nerve-elements.  On  the  other  hand, 
whether  the  changes  be  primary  or  secondary,  essential  or 
non-essential,  there  is  no  doubt  that  in  very  many  cases  the 
neurogHa  cells  and  fibres  show  morbid  conditions.  Karyo- 
kinetic  figures  may  at  times  be  discovered  in  the  nuclei  of  the 
gha  cells.  They  are  frequently  hypertrophied  and  apparently 
increased  in  number.  Bevan  Lewis  looks  upon  these  '  spider  ' 
cells  or  '  Deiter's  '  cells  as  '  phagocytes  '  or  '  Scavengers 
of  the  tissue,'  but  tliis  view  has  not  been  supported  by  any 
evidence,  experimental  or  otherwise,  (k)  Degenerative  changes 
may  be  found  in  the  medullated  tracts  of  the  spinal  cord, 
especially  in  the  posterior  and  lateral  columns.  They  occur 
likewise  in  the  spinal  roots  and  ganglia,  (l)  The  sympathetic 
ganglia  occasionally  show  nerve-ceU  and  vascular  changes. 
(???)  Degenerative  changes  have  been  recorded  in  the  peripheral 
nerves.  (??)  Fatty  degenerations  are  found  in  many  of  the 
organs  of  the  body,  and  atheromatous  changes  in  the  vessels. 

Cerebro-spinal  Fluid. — A  specimen  of  this  fluid  maybe  obtained 
without  injury  to  the  nervous  system  by  passing  a  hollow 
needle  into  the  spinal  canal  usually  between  the  fourth  and  fifth 
lumbar  laminse,  but  the  space  between  the  third  and  fourth 
lumbar  spines  can  be  used.  Place  the  patient  on  a  low  seat 
with  his  shoulders  touching  his  knees,  and  his  arms  passing 
between  his  knees  and  his  hands  touching  the  ground.  A 
straight  Une  drawn  across  the  back  at  the  level  of  the  highest 
point  of  the  ihac  crest  passes  over  the  fourth  lumbar  spine  ;  the 
puncture  is  made  immediately  below  the  spine.  Carefully 
sterihse  the  skin,  which,  if  desired,  can  then  be  rendered  anaes- 
thetic by  an  ethyl  chloride  spray  ;  the  operator  should  then  place 
his  left  forefinger  on  the  fourth  lumbar  spine,  and  with  his  right 
hand  push  in  the  needle  about  three  and  a  quarter  inches  (in 


GENERAL  PARALYSIS  OF  THE  INSANE  251 

the  adult),  the  sjjot  chosen  being  half  an  inch  below  and  half 
an  inch  to  the  right  of  the  spot  on  which  the  left  forefinger 
rests.  The  needle  should  be  dhected  horizontally  forwards  and 
inwards.  Push  firmly  on,  if  no  bone  is  struck.  If  the  latter 
occurs,  withdraw  the  needle  and  try  again  a  httle  higher  or 
lower.  Occasionally  during  the  passage  of  the  needle,  the 
patient  may  complain  of  a  sudden,  sharp  shooting  pain  dovim 
the  right  leg.  This  merely  means  that  the  needle  has  touched 
one  of  the  roots  of  the  cauda  equinse  and  is  of  no  importance. 
When  the  syringe  or  handle  is  removed,  the  fluid  should  drop 
from  the  end  of  the  needle.  If  the  latter  is  blocked,  it  must  be 
cleared  with  a  stiletto.  The  first  few  drops  of  fluid  should  be 
allowed  to  escape  as  there  may  be  a  Httle  blood  in  the  needle, 
then  collect  four  to  six  cubic  centimetres  in  a  sterilised  test- 
tube  and  close  with  sterilised  wool.  The  withdrawal  of  a 
small  quantity  of  cerebro-spinal  fluid  usually  gives  rise  to  no 
discomfort  afterwards,  but  in  a  small  proportion  of  cases  severe 
headache  follows,  and  this  is  more  common  if  the  patient  is 
allowed  to  walk  about  after  the  operation.  For  this  reason  it 
is  wise  to  keep  him  in  bed  for  some  hom'S. 

Normal  cerebro-spinal  fluid  is  colourless  (specific  gravity, 
1006-1008).  It  is  alkaUne  and  contains  a  trace  of  serum, 
globuhn,  and  of  albumose,  and  also  some  substance  which 
reduces  FehHng's  solution.  Microscopically  a  few  large  flat 
endothelial  plates  may  be  observed  and  also  a  very  occasional 
lymphocyte  (two  or  three  to  the  field).  The  nucleus  of  the 
endothehal  cells  is  '  horse-shoe  '  in  shape  and  does  not  stain 
so  deeply  as  that  of  the  lymphocyte. 

The  normal  cerebro-spinal  fluid  contains  no  polymorpho- 
nuclear leucocytes,  and  only  a  very  occasional  small  mono- 
nucleated  lymphocyte.  In  general  paralysis  there  is  a  very 
marked  lymphocytosis,  the  number  of  cells  averaging  from 
25  to  500  in  the  field.  This  condition  may  be  found  quite  early 
in  the  disease  and  is  therefore  of  great  diagnostic  value.  If 
examined  chemically,  the  cerebro-fluid  of  the  general  paralytic 
is  found  to  contain  an  excess  of  albumen,  and,  further,  Mott 
has  pointed  out  the  presence  of  cholin  in  these  cases.  In  all 
suspected  cases  of  general  paralysis  the  cerebro-spinal  fluid 
should  be  tested  by  Wassermann's  test,  and  it  is  found  to  be 
positive  in  a  large  number  of  cases. 


252  PSYCHOLOGICAL  MEDICINE 

Treatment. — The  treatment  of  general  jDaralysis  is  practi- 
cally confined  to  the  treatment  of  symptoms.  It  is  a  mortal 
malady,  but  nevertheless  much  can  be  done  by  alleviating  the 
symptoms.  The  patient  should  be  at  once  removed  from 
business  and  should  be  placed  under  the  constant  supervision 
of  a  relative  or  valet.  Complete  rest  is  absolutely  necessary 
and  a  general  paralytic  ought  never  to  be  sent  travelling  on 
the  Continent.  The  quieter  the  patient  is  kept  the  more 
slowly  will  the  disease  develop,  and  the  less  likelihood  will 
there  be  of  acute  excitement  supervening. 

In  treating  general  paralysis  the  physician  is  met  by  two 
difficulties  ;  in  the  first  place  the  relatives  rarely  believe  that 
the  diagnosis  is  true,  and  in  the  second  place  the  patient 
refuses  advice,  as  he  does  not  believe  himself  to  be  ill.  A 
careful  watch  must  be  kept  over  all  monetary  matters,  and 
the  friends  and  business  colleagues  of  the  patient  should  be 
warned  that  he  may  suddenly  show  a  tendency  to  reckless 
extravagance  and  within  a  short  time  prejudice  his  own  and 
their  credit.  If  a  patient  is  known  to  have  embarked  on 
some  wild  scheme,  or  to  be  negotiating  about  the  purchase 
of  some  property  which  he  neither  requires  nor  can  pay  for, 
immediate  steps  should  be  taken  to  warn  the  other  party  of  the 
mental  state  of  the  patient  and  to  tell  him  that  if  he  continues 
to  negotiate  he  does  it  at  his  own  risk.  The  usual  difficulty  is 
that  the  patient  is  deeply  involved  in  some  business  before  the 
transaction  is  known  to  his  friends.  If  possible,  get  him  away 
into  some  quiet  country  place ;  but  take  the  precaution,  wherever 
he  is,  to  have  plenty  of  assistance  within  reach,  as  patients 
with  this  disease  frequently  become  suddenly  unmanageable. 

If  the  patient  is  certifiable,  it  is  better  for  him  to  be  placed 
at  once  under  care.  If  the  case  has  to  be  treated  at  home  or 
in  a  private  house,  rules  should  be  drawn  up  both  as  to  the  diet 
and  general  management.  Moderate  exercise  should  be  ordered, 
and  this  is  by  no  means  easy  to  carry  out,  as  the  patient  is 
usually  restless  and  full  of  energy  and  will  not  be  satisfied 
with  less  than  twenty  miles  a  day  or  many  hours  of  golf 
or  other  games.  There  is  nothing  that  calls  for  greater  tact 
than  having  to  regulate  the  exuberant  sj)irits  of  the  general 
paralytic  in  the  early  stages.  With  physical  fatigue,  every 
symptom  from  which  he  suffers  will  become  exaggerated.     The 


PLATE  III. 

Brain  of  a  case  of  General  Paralj'sis  of  the  insane,  showing  vascular  conges- 
tion and  the  thickened  opalescent  pia-arachnoid  membrane  especially  marked 
in  the  frontal  and  parietal  regions. 


PLATE      II 


'i/ 


PLATE  IV. 

1. — Photograph  of  the  right  hemisphere  of  a  case  of  chronic  dementia  para- 
lytica, which  died  after  a  series  of  198  epileptiform  convulsions.  The  figure 
shows  wasting,  which  is  very  marked  in  the  pre-frontal  region  (anterior  two- 
thirds  of  the  first  and  second  and  anterior  part  of  the  third  frontal  gyrus)  ; 
marked  in  the  first  temporal  gyrus,  the  inferioi-  parietal  lobule,  Broca'.s  gyrus, 
and  the  lower  part  of  the  ascending  frontal  gyrus ;  fair]  y  marked  in  the  remainder 
of  the  sensori-motor  area  and  the  superior  parietal  lobule;  and  relatively  slight 
in  the  remainder  of  the  h?misphere,  including  the  orbital  surface. 

History. — Male,  aged  53  years,  married  18  years.  No  children.  Xo  family 
or  per.sonal  history.  In  Claybu.'y  Asylum  suffermg  from  chronic  dementia 
paralytica  for  nearly  three  years,  during  the  greater  part  of  which  time  he  Wci> 
lost  to  time  and  place,  and  wet  and  dirty  in  his  habits.  During  the  last  tvv.i 
years  of  his  illness  he  had  several  series  of  convulsions  and  eventually  died  a-^ 
above  stated.  Knee-jerks  absent.  L?ft  pupil  larger  than  right  and  both 
inactive  to  lisrht.     Tremor. 


2. — Photograph  of  the  left  hemisphere  of  a  more  acute  case  of  dementia 
paralytica,  which  died  of  chronic  tuberculous  pneumonia.  The  figure  shows 
wasting,  which  is  very  extreme  in  the  pre-frontal  region  ;  extreme  in  Broca's 
and  the  first  temporal  gyri  and  the  inferior  parietal  lobule  ;  marked  in  the 
rest  of  the  .sensori-motor  area  and  the  superior  parietal  lobule  ;  and  less  marked 
elsewhere,  including  the  orbital  surface  of  the  frontal  lobe.  Decortication 
exists  in  the  second  temporal  gyrus  and  the  pre-occipital  region,  into  whicli 
f)arts  the  disease  appears  to  be  rapidly  spreading. 

History. — Female,  aged  3f)  years,  married.  No  family  or  personal  history. 
In  Claybury  Asylum  suffering  from  dementia  paralytica  for  thirteen  months. 
On  admission  she  was  quiet  and  .somewhat  lo.st,  she  collected  rubbish,  and  .she 
»va.s  dirty  in  her  habits.  During  her  residence  she  had  several  (chiefiy  left- 
sided)  convulsions.  The  pupils  were  unequal.  The  right  knee-jerk  was  absent 
and  the  left  was  exaggerated.  Facial  and  lingual  trrnmrs.  Speech  slightly 
slulred.     Dierl  in  the  last  stage  of  (h^men^ia  jiaralytica. 

Figures  reproduced  from  Dr.  .1.  S.  Bolton's  paper  on  '  The  Histological 
Basis  of  Amentia  and  Dementia,'  Arrh'irea  of  Xevrolor/i/,  v6l.  ii. 


PLATE  IV. 


PLATE   V. 

1. — ^Outer  surface  of  the  left  hoiiiivsphere  of  the  brain  of  a  male  aged  41 
years.  Died  of  gross  dementia  pavalj'^tica.  The  duration  of  the  disease 
appears  to  have  been  little,  if  any,  more  than  two  years.  Heredity.  Syphilis. 
The  case  is  unusual  in  having  started  with  a  long  series  of  epileptiform  con- 
vulsions, after  whicli  the  patient  rapidly  became  grossly  demented.  Weight 
after  partial  stripping,  475  grammes.  The  wasting  is  very  extreme  in  the 
pre-fi'ontal  region,  and  extreme  in  the  whole  sensori-motor  region  (posterior 
thirds  of  the  first  and  second  frontal,  "Broca's,  and  the  ascending  frontal  gyri), 
and  in  the  first  temporal  gyrus,  the  superior  parietal  lobule,  and  the  pre- 
occipital region,  but  is  marked  elsewhere.  This  distribution  shows  fairly  well 
in  the  photograph,  but  is  much  more  clear  in  the  actual  hemisphere.  The 
unusually  early  and  marked  involvement  of  the  sensori-motor  area  was  evi- 
denced by  the  long  series  of  convulsions  which  ushered  in  the  disease.  As 
a  rule  the  first  temporal  gyrus  and  the  parietal  lobules  are  in  gross  and  chronic 
dementia  iiaralytica  more  wasted  than  the  sensori-motor  area,  though  this  is 
not  usually  visible  in  ordinary  gross  dementia.  This  is  probably  due  to  the 
fact  that  the  wasting  in  the  latter  is  rarely  so  rapid  and  extreme  as  it  is  in  the 
former,  and  consequently  the  differentiation  in  dementia  ])aralytica  is  more 
likely  to  be  the  true  one. 

Reproduced  from  Dr.  T.  8.  Bolton's  paper  on  '  Histological  Basis  of  Amentia 
and  Dementia,'  Archives  of  Xeumlogy,  vol.  ii. 


2. — Photograph  of  the  two  hemispheres  cut  horizontallj^  in  nearly  the  saem 
situation.  The  marked  atrophy  of  the  left  and  the  dilatation  of  its  ventricle 
are  very  obvious. 

(Reduced  one  half.) 

Reproduced  from  Dr.  Mott's  article  on  '  .Juvenile  General  Paralyis,'  Archives 
of  Neurolof/i/,  vol.  i. 


PLATE  V. 


--/^t  / 


2. 


PLATE  YI. 

1. — Microscopical  section  showing  increased  vascularity  of  the  cortex  in 
(.Teneral  Paralysis. 

(Stained  by  Xissl.     Magnification  50  diameters.) 

2. — Cortical  vessel  in  a  case  of  General  Paralysis  showing  perivascular  infil- 
tration with  lymphocytes  and  plasma  cells. 

(Stained  by  Nissl.     Magnification  180  diameters.) 

3. — A  section  through  the  floor  of  the  fourth  ventricle  showing  granula- 
tions of  tho  ependyma ;  a  very  characteristic  feature  of  General  Paralysis. 
(Magnification  50  diameters.) 

Drawn  by  A.  M.  Kelley. 


PLATE     VI 


♦/  iff  _  ^     <* 


"   .    "««;«'«      ^ 


mm 


/ 


.f^' 


<,  ^ 


,."-' 


i     J 


.in^i^-ifHift^--  .  ttil^  «Y«)({i^' 


■'1  -^lit  -^tliir.'Hi- 


./(ill  I 


:  PLATE  VII. 

Tvj'Es  OF  Change  affecting  the  Nekve  Cells. 
All  the  drawings  were  made  from  cells  of  the  cortex  cerebri. 

J . — Shows  fairh'  advanced  chronic  degeneration. 

2. — -Swelling   of   the   cell   body   and  nucleus,  with  chromatolysis  affecting 
especially  the  periphery  of  the  cell. 

3. — A  more  advanced  stage  of  a  similar  change,  chromatolysis  with  destnic- 
tiou  of  the  cellular  reticulum  and  displacement  of  the  nucleus. 

4,  5,  and  6. — Stages  of  a  similar  change  affecting  smaller  cellr<. 

Drawn  by  A.  M.  Kelley. 

{Continued  Piatt  VIII.) 


PLATE     VII 


r^^ 


u) 


4  f^' 


m(dn 


,''   ^ 


T1' 

'0 


■    I        ^ 


,*j,  .  f 


rr 


@     1%^^^-' 


^•f 


^M^A 


t>^<:i 


•^.\ 


V 


f 


^)  > . 


f 


/' 


■s^^^' 


>?^^  ^ 

*  ^);-<^ 


m*.x 


PLATE   VIII. 

(Conlinvcd  from  Plate  VII.) 
Types  of  CHAXftE  affecting  the  Nerve  Cells. 

All  the  drawings  were  made  from  cells  of  the  cortex  cerebri,  excepting  1, 
which  is  a  cell  of  the  dentate  nricleus  of  the  cerebellum. 

1,  2,  and  3. — Chromatolysis  and  vacuolation,  with  much  breaking  down  of 
the  cellular  reticulum  in  2. 

■i  and  5. — Coagulation  necrosis. 

(One-twelfth  Leitz  oil  immersion  lens  and  No.  -1  ocular :    after  reducing    to 
two-thirds  of  size,  magniiication  of  above  will  be  correct.) 

Reproduced  from  Dr.  G.  A.  Watson's  paper  on  '  Histology  of  Cleneral  Para- 
lysis,' Archives  of  Neurology,  \o\.  ii. 

Drawn  by  A.  M.  Kelley, 


PLATE     Vlll 


^.^ 


"5:. 


r 


I 


PLATE   IX. 

1. — Pj^amidal  cell  of  a  dog  aftei'  ligation  of  two  carotids,  one  verteliral 
and  one  subclavian.  Great  swelling  of  the  nucleus,  advanced  chroraatolysis 
most  marked  at  the  periphery  of  the  cell.     (Magnification  700  diameters.) 

2. — Pyramidal  cell  of  a  dog  after  ligation  of  arteries,  shoAving  extreme 
ihromatolysis  with  commencing  extrusion  of  the  nucleus.  ( Magnification  700 
diameters.) 

3. — Pyramidal  cell,  Mith  diffuse  staining,  from  a  cat,  after  ligation  of  four 
cerebral   arteries.     (Magnification   .")00   diameters.) 

4. — Pyramidal  cell  fiom  a  monkey  five  days  after  ligation  of  two  carotitls 
and  one  vertebral,  showing  swelling  in  the  pyramidal  cell  with  diffuse  homo-  ' 
geneous  staining  owing  to  the  stainable  substance  being  scattered  through  the 
protoplasm  of  the  cell  as  fine  dust. 

o. — )Shows  a  ('ell  with  commencing  chromolytic  change. 

6. — Shows  a  cell  with  advanced  chromolytic  change  and  eccentric  nucleus. 
Both  of  these  cells  resemble  the  appearances  presented  by  cells  after  section  of 
a  nerve,  and  the  change  may  be  due  to  the  morbid  process  having  causcft 
destruction  of  the  axis-cjdinder  process.  They,  however,  are  capable  of 
regenerating  the  axis-cylinder  process,  as  may  also  occur  after,  section 
of  a  nerve. 

7  and  8. — Show  morjihological  changes  indicating  death  of  the  trophic 
and  genetic  centre.  We  see  in  7  a  concavity  on  one  side  indicating  ruyiture 
of  tiu'  nuclear'  membrane,  and  in  8  there  is  so  much  vacuolation  of  tlie  proto. 
j)lastn  of  tlic  cell  as  to  indicate  its  destruction. 

(Reduction  of  drawings  to  two-thirds  of  present  si?e  will  gise  correct  magniH- 
oation.) 

Drawn  by  A.  .M.  Kelley. 

Reproduced  from  Dr.  Mott's  Croonian  I.,ecturcs,  1900,  on  '  Degeneration  of 
the  Neuron.' 


PLATE      IX 


■i4!i^^^^^^}i 


^r 


PLATE  X. 

The  Braix-Cells  in  Status  Epileptictjs. 

1. — ^Normal  cell,  for  comparison. 

2, — Cell  from  ease  of  status  epilepticus,  showing  an  incrustation  of  fine  blue 
particles  upon  the  delicate  fibrillse  of  the  achromatic  network. 

1  and  2  original  magnification  750  diameters. 
Drawn  by  A.  M.  Kelley. 

Reduction  to  two-thirds  of  present  size  will  give  original  magnification. 
{Continued  Plates  XL,  XII.  and  XII I.) 


PLATE     X 


m 


filf     ' 

I'll/ 


.II//I  .1/,  ./ 


PLATE    XI. 

The  BBAi>i-<L*Eixs  rs  .STATrs  Epilieptict-s. 
{Canii»Med  from  Plate  X. ) 

Figure  fliastrate$  same  points  as  2.  Piate  X.     Original  magnification  lod 
diwneten. 

Drawn  by  A.  M.  Kelley. 

Bednction  to  two-thirds  of  present  size  will  give  original  magnification. 
{Cmttiftrntd  Plaits  XII.  and  XIII.) 


f 


't) 


PLATE    XI 


%     G) 


t 


#- 


PLATE   XII. 

The  Brain-Cells  ix  Status  Epilepticus. 
{Continii.ed  from  flutes  X.  and  XI.) 

1. — Cell  from  hyiioglossal  nucleus.  There  is  commencing  chromatolysis 
at  the  border  of  the  cell,  and  the  nucleus  is  larger  and  more  distinct  than 
normal ;  the  chromatic  spindles  are  still  present  in  the  processes,  and  the 
Nissl  Vjodics  are  very  evident  in  the  substance  of  the  cell. 

2.  —Illustrates  the  same  points  as  2,  Plate  X.  and  Plate  XT.,  but  the  chroraa- 
tolysis  is  more  extensive. 

Dra^\■n  by  A.  ^I.  Kelley. 
Original  magnification  1000  diameters. 

Reduction  to  two-thirds  of  present  size  will  give  original  magnification. 
{Continned  Plate  XIII.) 


PLATE    Xll 


M^. 


':  PLATE   XIII. 

The  Beaix-Cells  ln  Status  Epii.KPTirrs. 
(Continued  from  Plates  X..  XT.  ond  XII.) 

Tiic  iigure  shows  distension  of  the  perivascular  lymphatics  ;  after  experi- 
mental ligation  of  the'carotids. 

Original  magnitieation  750  diameters. 

Reduction  to  two-thirds  of  present  size  will  give  original  magnitieation. 

Drawn  In-  A.  M.  Kelley. 

Plates  X.,  XI.,  XII.  and  XIII.  are  enlarged  reproductions  of  drawings  illus- 
trating Dr.  Mott's  paper  on  '  Changes  in  the  Brain.  &c...  foimd  in  Persons  dj'ing 
after  prolonged  Epileptiform  Convulsions,'  Archives  of  Nevrolncjy,  vol.  i. 


PLATE    XIII 


I 


^ 


1.:/ 


r 


^i 


'V  \ 


6:^ 


^ 


vN 


PLATE   XIV. 

To  Show  Cheomatolysis. 

1. — Pyramidal  cell  of  a  dog  after  ligation  of  two  carotids,  one  vertebral 
and  one  subclavian.  Great  swelling  of  the  nuclei ;  advanced  chromatolysis 
most  marked  at  the  periphery  of  the  cell.     Magnification  700. 

2. — Pyramidal  cell  with  diffuse  stainmg  from  a  cat  after  ligation  of  four 
cerebral  arteries.     Magnification  .500. 


3. — Antei'ior  horn  cell  of  spinal  cord  fi'oni  a  gi;inea-pig  wliich  died  forty- 
live  hours  after  injection  of  0"2  mg.  of  abrus-globin.  ^AU  the  cells  showed 
this  diffuse  staining  and  abisence  of  Nissl  granules.     Magnification  400. 

f . — Section  of  tlie  spinal  cord  of  a  case  of  Congo  sickness  with  hyperpyrexia, 
in  which  the  temperature  reached  109°  F.  prior  to  death.  The  whole  of  the 
cells  throughout  the  central  nervous  system  showed  a  diffuse  homogeneous  dull 
staining.  The  Nissl  granules  had  entirely  disappeared  from  the  processes  and 
tlie  body  of  the  cell,  and  the  stainable  substance  had  a  fine  dust-like  appear- 
ance. The  processes  arc  unusually  distinct,  tlic  nucleus  is  clear  and  swollen, 
faintly  stained,  and  the  nucleolus  deeply  stained.  Magnification  4ft0. 
{Contivued  Plate  XV.) 


PLATE  XIV. 


PLATE   XV. 

{Continued  from.  Plate  XIV.) 

]• — Pyramidal  cell  from  cortex  of  monkey,  stained  by  rapid  Golgi  method, 
showing  gemmules  on  the  dendrons  and  all  the  external  appearances  of  a 
)iormal  cell.     Magnification   150. 

2. — Section  of  pj'ramidal  tract  of  spinal  cord  of  monkey  ten  days  after 
ligation  of  two  carotids  and  one  vertebral.  A  few  scattered  degenerated  fibres 
are  revealed  In^  the  Marchi  method.  These  were  more  numerous  on  the  side 
opposite  to  the  hemisphere  on  which  the  vertebral  artery  was  ligatured,  but 
altogether  not  more  than  sixty  in  number,  so  that  only  an  inconsiderable 
number  of  the  psycho-.motor  cells  had  perished  as  a  result  of  the  ansemia. 


3. — ^Axis-cylinder  process  from  a  large  pyramidal  cell,  tlie  lymph  space 
around  which  is  distended,  and  showing  the  collateral  side  branches  apparently 
forming  a  diffuse  nerve  network.     Magnification  1000. 

4. — .Swollen  (*demat(jus  ccUfi'om  the  top  of  .the  ascending  fiontal  convolution, 
with  diffuse  staining  and  absence  of  Nissl  granules,  from  a  case  of  status  epilep- 
ticus.  Xote  the  convex  borders  as  compared  with  the  concave  and  straight 
bordiMs  of  the  normal  cell  in  1,  Plate  X.     Magnification  700. 

Plates  XV.  and  X\'l.,  reproduced  from  Dr.  Mott's  Oroonian  Lectures,  IHOD, 
'  Dagoneration  of  the  Neuron.'  as  published  in  the  liriti-^h  Medical  Journal. 


PLATE  XV. 


PLATE   XVI. 

/ 

Photomicrograpb  of  strips  of  the  brain,  which  are  from  left  to  right. 
1.  Small  and  medium-sized  pjTamidal  layer,  top  of  ascending  frontal,  show- 
ing abolition  of  Mejiiert's  columns  produced  by  destruction  and  distoi-tion  of 
the  pyramids.  Not  a  healthy  cell  is  .seen.  There  is  marked  proliferation  of  glia 
cells.  2.  The  same  section  of  the  cortex  in  the  deeper  layer  of  large  pyramids. 
Two  Betz  cells  are  seen  together ;  one  is  obviously  destroyed,  and  has  been 
partially  devouiod  by  ])hagocji:es.  Most  of  the  cells  are  abnormal.  3.  Pyra- 
midal layers  of  occipital  cortex.  Both  as  to  numbers  and  conformation  they 
present  a  compaiatively  normal  appearance,  i.  Broca's  convolution,  very 
marked  dcstriKtion  of  medium-sized  pyramids  sliown. 

P^produced  from  Dr.  F.  rMott's  paper  on  '  1  abes  in  Asylum  Practice,' 
Archives  of  Xfurnlof/ij,  vol.  ii. 


PLATE  XVI. 


\c 


■ 

1 

r  ^   4 

1 

f4. 

t 

1 

1 

-.'■«# 

I 

ii'  . 

■ 

1  • 

Jl 

f.%. 

1. 


4. 


PLATE  XVH. 

1, — Photomicrograph.  Section  of  central  convolution  stained  by  Nissl 
method,  to  show  acute  degenerative  changes  in  the  pyramidal  cells.  Magni- 
fication 250  diameters. 


2  and  3. — Photomicrographs.  Section  of  top  of  ascending  frontal,  left 
hemisphere,  stained  by  Nissl  method,  showing  atrophy  of  superficial  layers 
of  cells  especially,  without  glia  proliferation.  Compare  with  other  figure  from 
normal  brain.     Magnification  200  diameters. 

Reproduced  from  Dr.  F.  Mott's  paper  on  'Juvenile.  General  Paralysis,' 
Archives  of  Nenrology,  vol.  i. 


PLATE  XVII. 


l1 


.-1 


i       -.-, 


^'        t..'^      \A 


PLATE  XVIII. 

Section  (b)  from  the  ascending  frontal  convolution  from  a  case  of  General 
Paralysis,  showing  distortion  and  diminution  in  the  number  of  the  pyramidal 
cells  and  irregularity  of  the  cell  layers  as  compared  with  a  normal  section  (a). 
There  is  an  abundance  of  round  nuclei  which  are  the  nuclei  of  nem'oglia  cells 
and  lymphocytes. 

(Stained  by  Nissl  method.     Magnification  50  diameters.) 

Drawn  by  A.  M.  Kelley. 


PLATE     XVIII 


i>*.>^..^ 


X 


•:^ 


is'.  '   .    .       <* 


^^•    -  V  !•    ■•  •  i    «  '  A  -  •       - 

^.":    4  ■>■  f'C   ,.    ^      !.    <•    •■-  -f 

. ,   ?.  li .  -L  ■'    .        >     -^ 

V  \i' '  V  A  '■    '■   '  "'■ '  '^  '' 

.-;■  ,-,  ,  :  -i];      ••;-■■  t 


•=;    6 


f   ••. 


^    < 


4:   ' 


i     -iVf- 


<  7  ■  ^; 


'  '  ;  >  ,.'*■  "1   %' 


■t. ;  '\' 


'<  <  J' 


:^  V  c>-^  •.  ,  i  '•  ■.; 


V      > 


■I    .;)    .'/l    iricn 


PLATE    XIX. 

Phases  in  the  development  of  neuroglia  cells  and  fibrils. 

The  drawings  are  all  from  cells  of  the  cortex  cerebri  stained  by  Heidenhain- 
Erythrosin  method.  They  ap]3ear  somewhat  diagrammatic,  partly  from  being 
drawn  in  one  plane,  and  partly  owing  to  the  process  of  reproduction,  but  are 
really  little  more  so  than  the  preparations  show.  The  paits  shaded  grej"  are 
stained  pink  in  the  specimens. 

1,  a  and  b. — Dividing  neuroglia  nuclei  sm-rounded  hy  an  indefinite  amount 
of  protoplasm. 

2,  a  and  b. — Protoplasmic  processes  more  definitely  formed. 

3,  a  and  b. — Commencing  condensation  of  protoplasmic  processes  producing 
darkly  staining  fibrils. 

4,  a,  h,  and  c. — Show  mode  of  attachment  of  tiie  processes  to  a  vessel-wall. 
In  a  and  h  there  is  apparent  partial  differentiation  of  the  protoplasm  of  the 
'  foot '  into  fibrils. 

5,  a  and  h.  —  Further  development  of  fibrils.  The  nucleus  is  more  darkly 
stained,  and  in  h  tlie  pink-stained  protoplasm  somewhat  less  in  amoimt ; 
a  shows  a  '  recurved,'  and  h  '  bifurcated  '  fibrils. 

(). — Th<'  protoplasm  is  almost  entiicly  (lifTcrentiated  into  fibrils,  and  the 
nucleus  is  shrunken  and  stains  darkly. 

One-twelfth  oil  immersion  lens  and  No.  4  ocidar. 

Reproduced  from  Dr.  0.  Watson's  paper  on  '  Histology  of  CJcneral  Para- 
lysi.s,'  Arcliivcfi  of  Xeurohxjij,  vol.  ii. 


PLATE  XIX. 


.A. 


«   J      N 


b 


a 


;#'* 


2. 


1 

f 
3  a. 


PLATE   XX. 

PpvOlifebatixg  Glia  Cells  ix  General  Paralysis. 

Zeiss  oil  immer.  2""",  ocular  4. 

From    Dr.    Watson's    sijeciniens,    stained    by    the    Heidenhain-Erythrosia 
method. 

Diawn  by  A.  M.  Kelley, 


PLATE     XX 


\ 


>^ 


^ 


'C       \ 


PLATE, XXI. 

Photomicrograph  showhig  glia  changes  in  juvenile  general  iiaralysis.  Taken 
from  the  cortex  of  the  calcarine  area.  Two  sides  of  a  sulcus  with  a  portion 
of  the  cortex  on  either  side.  Shows  much  thickening  of  pia  with  cell  infiltra- 
tion. Congestion  and  thickening  of  the  vessels,  also  numerous  thickened 
vessels  passing  from  the  pia  into  the  outer  part  of  the  cortex.  Coincident  with 
this  is  much  active  glia  proliferation  with  considerable  fi,brillation  in  the  outer 
part  of  the  cortex.  These  changes  are  not  so  marked  as  occur  in  other  parts  of 
the  cortex,  but  the  photograjih  is  of  interest  in  proving  that  characteristic 
changes  do  take  place  in  the  occipital  region,  and  are  not  confined  to  tlic  central 
cortex,  as  some  authoi'ities  assert. 

From  Dr.  (!!eorgc  Watson's  specimen. 


PLATE  XXI. 


PLATE   XXII. 

1. — Disappearance  of  the  lumen  of  a  capillary  by  proliferation  of  the  endo- 
thelial cells,  with  three  plasma  cells  shown  (dementia  paralytica). 

2. — Sprouting  of  the  endothelial  cells  of  capillaries  with  junction  of  two 
adjacent  vessels  (demeirtia  paralj'tica). 

3. — Endothelial  prolifeiation  with  sprouting  of  the  capillary,  surrounded  by 
numerous  adventitial  cells  (dementia"  ]iaralytica). 

i. — Transverse  section  of  a  small  vessel  of  the  pia  mater,  with  a  double 
layer  of  enormously  swollen  endothelial  cells  (dementia  paralytica). 

{Continned  Plak  XX HI.) 


PLATE    XXII 


^> 


ad.c 


T»^-  r,":is^^_ 


pl.c — plasma  oell         e.c— endothelial  cell         ad.c — adventitial  cell 

e.sp.c — endothelial  sprouting  cell 

I — lumen        m.c — mast  cell        Ic — lymphocyte 


PLATE    XXIII. 

(Continued  from  Plate  XXII.) 

1. — O'apillary  from  the  deep  layer  of  the  cortex.  Marked  overgrowth  of 
the  endothelial  cells  (dementia  paralytica). 

2. — Longitudinal  section  of  a  vessel  from  the  deep  layer  of  the  cortex.  In- 
filtration of  the  adventitial  sheath  with  large  j)lasma  cells  and  mast  cells 
(dementia  paralytica). 

■i. — Longitudinal  section  of  a  vessel  from  the  spinal  cord,  showing  marked 
jjroliferation  of  the  endothelial  cells  within  the  lymphatic  sheath.  Very 
numerous  lymphocytes  and  plasma  cells ;  from  case  of  syphilitic  meningo- 
myelitis. 

Plates  XXIL  and  XXIII. — After  A.  Alzheimer,  from  HiAtologischc  Stndien 
ziir  Differenzl(ddiacjno<ie  der  pror/res-siven  P<trnlyse. 

Drawings  hy  A.  ^I.  Kelley. 


PLATE    XXIII 


T-. 


c^: 


otl.r 


e.sp.  c 


:y 


'• «:»'../     (y 


<5jj,       Ci^i^-V;^ 


^ 


(S> 


^'^^ 


^ 


^ 


fv^        C-j)C^^/?)?=r 


-^oo 


€^ 


^ 


© 


6- 


'^ 


1^  #  »<^.  i^ 


^»>      e.  c 


joi-.c 


^.c-plasma  cell         ..c-endothelial  cell         arf.c-adventit.al  cell 

e.«p.c— endothelial  sprouting  cell 

^-lumen        m.c-ma8t  cell         ^-lymphocyte 


PLATE  XXIV. 

Sections  of  the  motor  cortex  (b)  showing  atrophy  of  the  tangential,  supra- 
radial  and  intra-radial  system  of  fibres  in  General  Paralysis,  contrasted  with 
the  normal  (a). 

(Stainwl  by  VVeigert  Pal  method.     Magnification  50  diameters.) 

Drawn  by  A.  M.  Kelley. 


PLATE  XXIV. 


PLATE  XXV. 

1. — Section  of  cerebral  cortex,  stained  by  Kultscbitzky-Wolters  method, 
showing  normal  medullated  fibres,   x  25. 


2. — Stained  as  above  ;    from  case  of  acute  excitement ;    section  shows  no 
abnormal  change. 

(Cotilinmd  Plate  XXV I.) 


PLATE  XXV. 


PLATE   XXVI. 

(Continued'  from  Plate  XXV.) 

1. — Section   of  cerebral  cortex  stained   by   Kultschitzky- Welters   method, 
showing  tortuosity  of  the  radiations  from  a  case  of  dcinentia  paralytica,  x  300. 


2. — Section  of  cerebral  cortex  stained  as  above,  showin<^  extreme  destruction 
of  fibres,  including  radiations,  fibres  almost  entirely  absent.  Greatly  increased 
vascularity  and  chrome-infiltration,  from  case  of  dementia  paralytica,  x  35. 

Pliotoniicroj^raphs  on  Plates  XXV.  and  XXVI.,  oj'iginally  publislied  by 
Dr.  Goodall  in  Brain,  vol.  xxiii.,  to  illustrate  paper  on  '  Condition  of  Medullated 
H'ibres  in  Insanity.' 


PLATE  XXVI. 


PLATE  XXVII. 

Microscopic  appearance  of  the  centrifugal  deposit  from  the  cerebro-spinal 
fluid  of  a  General  Paralytic,,  sliowing  lymphocj-tosis.  (Lcishnuin's  stain. 
One-twelfth  inch  Oil  Immersion.) 

Drawn  bv  A.  M.  KcUev. 


PLATE     XXVII 


•km* 


m        & 


GENERAL  PARALYSIS  OF  THE  INSANE  253 

diet  should  be  light  and  nutritious.  Meat  should  be  restricted 
and  all  alcohol  forbidden.  Sexual  intercourse  should  not  be 
permitted.  Drugs  are  of  little  value  in  the  early  treatment 
of  general  paralysis.  When  there  is  insomnia  hypnotics  should 
be  given,  if  ^food  and  regular  living  have  faded  to  produce 
sleep.  Anti-syphilitic  treatment  is  usually  of  not  much 
value  and  in  some  cases  may  aggravate  the  symptoms  ; 
nevertheless  it  is  right  that  it  should  be  tried.  It  i^  advised 
that  smaU  doses  should  be  administered  at  first.  The  bowels 
require  careful  attention.  Eetention  of  urine  is  a  symptom 
which  may  give  trouble,  and  it  is  necessary  for  the  attendant 
to  see  that  the  urine  is  passed  in  sufficient  quantities. 
'  Seizures  '  may  occur  at  any  time,  and  the  valet  should  be 
warned  not  to  allow  the  patient  to  walk  or  stand  m  dangerous 
places  ;  for  the  same  reason  he  should  not  be  left  alone  at 
night.  Trephining  of  the  skull  and  drainage  of  the  sub -arach- 
noid fluid  has  been  tried,  on  the  theory  held  by  some  authorities 
that  the  symptoms  are  largely  due  to  pressure.  But  this 
mode  of  treatment  has  not  proved  of  much  benefit ;  remissions 
have  occurred  in  patients  so  treated,  but  not  in  greater  pro- 
portion than  in  the  untrephined  cases.  Townsend  has  reported 
on  the  value  of  urotropine  in  the  treatment  of  general  para- 
tysis.  The  dose  is  usually  seven  to  ten  grains  two  or  three 
times  a  day. 

In  the  later  stages  of  the  disease  careful  nursing  is  very 
requisite.  The  food  should  be  minced  and  the  patient  prevented 
from  trying  to  eat  too  quickly,  otherwise  he  may  choke  himself. 
Great  care  should  be  exercised  in  handling  a  general  paralytic, 
as  he  not  only  bruises  readily,  but  his  bones  are  very  brittle. 
If  the  patient  is  unconscious  for  any  length  of  time  owing  to 
a  series  of  convulsions,  he  must  be  turned  constant^  from 
side  to  side,  otherwise  bed-sores  wiU  form.  The  bowels  also 
require  continual  care.  The  temperature  should  be  taken 
morning  and  evening,  as  fever  may  be  the  first  warning  of 
some  intercurrent  comphcation  or  of  the  accession  of  a  seizure. 
"When  the  patient  becomes  bedridden  it  is  very  advisable  to 
place  him  on  a  water  bed,  as  bed-sores  are  apt  rapidly  to 
form. 


254  PSYCHOLOGICAL  MEDICINE 


GHAPTEE  XV 

EXHAUSTION  PSYCHOSES  :    NERVE  EXHAUSTION  AND  NEURAS- 
THENIA,  ACUTE   HALLUCINATORY  INSANITY 

Nerve  Exhaustion  and  Neurasthenia 

In  many  ways  these  disorders  are  synonymous,  but  the 
writer  for  convenience  has  always  reserved  the  term  Neuras- 
thenia to  denote  those  cases  which  exhibit  a  marked  tendency 
to  nerve  fatigue  throughout  hfe  and  in  which  there  are  associated 
marked  disturbances  of  the  various  organs  of  the  body,  more 
especially  the  stomach.  On  the  other  hand  nerve  exhaustion 
may  be  transient  a.nd  the  patient  suffers  from  isolated  attacks, 
some  physical  or  mental  stress  being  almost  always  found  to 
account  for  it.  It  must  also  be  borne  in  mind  that  in  fatigue 
states  the  symptoms  include  disturbances  both  bodily  and 
mental. 

Exhaustion  symptoms,  which  may  pass  on  to  acute  confu- 
sional  insanity,  may  arise  during  treatment  with  vaccines  if 
the  doses  are  large ;  this  is  especially  the  case  with  Bacillus  Coh. 
.ffitiology. — Neurasthenia  usually  declares  itself,  maybe  at 
first  only  in  very  minor  ways,  soon  after  puberty  and  is  found 
both  among  the  rich  and  the  poor.  The  parents  of  the  patient 
are  frequently  neurotic  persons,  and  very  commonly  one  or 
other  has  been  addicted  to  some  form  of  excess.  As  already 
stated,  the  stress  of  puberty  may  be  the  determining  cause  ; 
or,  in  some  cases,  close  school  work  and  early  examinations 
are  the  exciting  factor.  The  nerve  exhaustion  of  later  life  is 
produced  by  various  stresses  which  differ  to  a  certain  extent 
in  the  two  sexes.  In  the  female  monorrhagia  or  metrorrhagia 
are  by  far  the  most  common  causes,  but  in  some  cases  domestic 
strains  have  played  a  part.  In  men  excesses  of  all  kinds,  such 
as  alcohoUsm  or  venery,  may  undermine  the  nervous  energy, 
or  the  nerve  exhaustion  conditions  may  result  from  work  done 


NERVE  EXHAUSTION  AND  NEURASTHENIA  255 

at  high  pressure  or  for  too  continuous  a  time.  Pyorrhoea  and 
a  septic  condition  of  the  mouth  is  not  an  uncommon  factor. 
Irregularity  in  meals  and  neglect  to  take  proper  hours  of  rest 
are  fertile  causes  in  the  production  of  nerve  exhaustion.  Many 
men,  having  spent  their  days  in  close  offices,  will  sit  up  night 
after  night  in  vitiated  atmospheres  until  the  early  hours  of 
the  morning  :  or  will  cany  on  their  lousiness  with  such  feverish 
energy  that  they  forget  or  neglect  the  midday  meal.  Sleepless- 
ness will  soon  produce  this  disorder,  and  this  war  has  produced 
large  numbers  of  cases  ;  these  are  referred  to  elsewhere. 
Injuries  or  shocks  may  produce  the  condition.  Exhausting 
illness  may  be  followed  by  a  long  period  of  neurasthenia. 
Another  important  factor  in  the  production  of  nerve  exhaustion 
is  dysentery,  or  too  free  action  of  the  bowels  for  some  length 
of  period,  especially  if  this  has  been  followed  b}^  colitis.  Too 
violent  athletic  exercises  may  produce  this  disorder  in  either 
sex.  A  neurotic  inheritance  is  by  no  means  a  constant  factor 
in  the  history  of  these  cases.  No  race  seems  to  be  exempt 
from  the  disorder,  though  the  causes  probahly  vary  in  diilerent 
countries. 

Mental  Symptoms.  —  The  mental  symptoms  are  almost 
identical  Avith  those  foimd  in  ordinary  fatigue,  but  as 
neurasthenia  is  a  more  chronic  condition,  the  symptoms  will 
be  found  to  be  more  fully  developed.  Every  mental  attribute 
is  affected,  but  the  latest  acquired  and  least  organised  suffer 
most.  Irritabihty  and  loss  of  control  are  prominent  symptoms. 
The  presence  of  chattering  children  in  a  room  quickly  fatigues 
persons  in  this  condition  and  in  course  of  time  becomes  un- 
endurable. Clocks  and  other  monotonous  sounds  have  to 
be  stopped,  as  they  cause  severe  mental  pain.  Mental  con- 
centration becomes  difficult  or  impossible.  Attention  rapidly 
fails  and  its  failure  is  soon  reflected  on  the  memory.  Names 
and  details  caimot  be  remembered  and  business  capacity 
decreases.  Obsessions  and  vague  fears  arise  ;  so  simple  a  task 
as  the  crossing  of  a  street  may  cause  suffering.  The  nerve 
exhaustion  patient  usually  recognises  the  folly  of  his  fears,  but 
cannot  dispel  them.  A  sense  of  giddiness  is  not  uncommon  ; 
it  is  not  a  true  vertigo,  but  rather  a  feeling  of  lightness  or 
'  swimming  in  the  head.'  The  legs  feel  as  if  they  were  not  under 
proper  control,  and  jerky  movements  may  also  be  observed. 


256  PSYCHOLOGICAL  MEDICINE 

The  emotional  tone  is  one  oi  depression^  but  this  vaiies  at 
different  times  and  is  not  constant  as  in  the  maniacal-depressive 
states.  One  of  the  characteristics  of  the  true  neurasthenic 
is  the  deficiency  of  voluntary  action.  All  effort  leads  to  an 
intense  feeling  of  fatigue. 

He  complains  that  he  cannot  think,  that  his  mind  seems  a 
blank,  and  that  he  feels  nervous  when  spoken  to.  His  speech 
often  becomes  hesitating,  and  he  may  stumble  in  pronouncing 
words.  Sooner  or  later  he  becomes  anxious  about  himself 
and  may  fear  that  he  is  losing  his  reason.  Hypochondriacal 
feelings  slowly  develop,  and  the  patient  begins  to  explain  his 
various  symptoms.  In  some  cases  he  will  refer  everything  to 
his  head,  and  may  even  develop  delusions.  Headache  and  other 
disordered  cerebral  feelings  are  common.  Other  patients  com- 
plain of  spinal  weakness.  This  symptom  is  not  uncommon 
in  persons  who  have  been  in  a  railway  accident  ;  in  such  a  case 
the  sense  of  weakness  m.ay  have  arisen  from  some  slight  spinal 
concussion.  Women  chiefly  complain  of  continual  pain  in  the 
lower  part  of  the  back  or  in  the  coccyx,  others  of  pain  in  the 
back  of  the  neck. 

Another  class  of  patients  refer  their  condition  to  gastro- 
intestinal weakness  or  disturbance,  and  sufferers  of  this  type 
may  starve  themselves  under  the  belief  that  they  are  unable 
to  digest  any  food.  They  will  gradually  eliminate  various 
classes  of  food  from  their  dietary,  until  at  length  there  is  nothing 
that  they  can  take.  In  such  cases  constipation  is  a  common  and 
troublesome  symptom.  The  sexual  variety  of  neurasthenia  is 
perhaps  one  of  the  most  frequent  types.  TTie  patient  believes 
himself  to  be  impotent,  and  not  infrequently  adds  to  his 
mental  distress  by  reading  quack  literature  on  the  subject. 
Spermatorrhoea  may  be  a  prominent  symptom,  and  the  fre- 
quency of  the  emissions  may  tend  further  to  weaken  the 
patient.  Lack  of  confidence  interferes  with  the  due  discharge 
of  daily  work  ;  the  patient  becomes  introspective,  and  may,  if 
untreated,  develop  acute  depression  with  suicidal  tendencies. 
In  fact  all  patients  suffering  from  any  severe  degree  of  nerve 
exhaustion  must  be  regarded  as  suicidal,  as  they  commonly 
destroy  themselves  by  some  impulsive  act. 

Physical  Symptoms. — Insomnia  is  an  early  and  trying 
symptom    in    neurasthenia    and    nerve    exhaustion.      Some 


NERVE  EXHAUSTION  AND  NEURASTHENIA  257 

patients  fail  to  get  off  to  sleep,  others  wake  within  an  hour  or 
two  of  retiring  to  rest,  and  others  wake  constantly  throughout 
the  night.  Even  the  sleep  that  is  obtained  is  not  refreshing. 
However  tired  and  sleepy  a  patient  feels  before  going  to  rest, 
immediately  he  gets  to  bed  his  brain  becomes  active.  He 
begins  to  dread  the  nights  and  frequently  sits  up  reading  or 
spends  many  hours  walking  about  the  bedroom.  Hearing 
seems  to  be  accentuated  ;  every  little  noise  worries  the  invalid. 
Indigestion  is  a  common  symptom  and  is  usually  accompanied 
by  constipation.  The  neurasthenic  complains  of  '  flutterings  ' 
and  palpitation  about  the  heart.  Sweating  and  blushing 
occur  readily.  The  pupils  are  widely  dilated,  but  there  is  no 
lessening  of  the  visual  field  as  is  usually  found  in  hysteria. 
The  superficial  and  deep  reflexes  are  exaggerated.  The 
muscles  are  in  an  irritable  condition  and  react  readily  to  slight 
stimuli.  One  patient  will  complain  that  his  legs  seem  to  be 
always  trembling.  Others  will  tell  you  that  the  limbs  jump 
as  they  fall  off  to  sleep.  Tremors  of  the  facial  muscles  are 
common.  In  others  the  body  weight  falls  and  two  or  three 
stones  may  be  quickly  lost.  The  complexion  is  anaemic  and 
the  blood-pressure  is  low.  Many  of  these  patients  suffer  from 
a  nasal  catarrh  and  complain  of  a  blocking  of  the  nasal  passages, 
either  when  lying  or  standing  or  with  both.  The  extremities  are 
cold.  The  most  common  feature  is  some  disorder  of  sensation, 
and  in  the  severe  cases  it  is  this  disordered  sensation  which 
so  frequently  leads  to  the  developm^ent  of  delusions.  Singing 
in  the  ears  and  the  sound  of  a  distant  bell  are  common  aural 
disturbances,  and  there  are  visual  hallucinations  in  the  half- 
asleep  or  half-awake  state  (hypnagogic).  The  headaches 
may  be  frontal,  or  be  a  bruised  feeling  on  the  top  of  the  head, 
or  maybe  a  dull  weight  in  the  region  of  the  occiput.  The 
general  nutrition  of  the  body  may  be  good,  for  neurasthenia 
may  develop  in  an  apparently  robust  individual. 

Course. — The  course  is  slow  and  tedious.  Neurasthenia 
develops  very  gradually.  At  first  the  symptoms  come  and  go 
rapidly.  Even  in  favourable  cases,  and  when  rigid  adher- 
ence is  given  to  the  prescribed  treatment,  the  course  may  be 
long.  If  advice  is  either  not  taken  or  not  followed,  the 
symptoms  slowly  and  steadily  become  more  marked  until 
a  definite  nervous  collapse  takes  place. 

17 


258  PSYCHOLOGICAL  MEDICINE 

Diagnosis. — As  with  hysteria,  neurasthenia  is  a  name  which 
is  made  to  include  a  great  variety  of  nervous  disorders.  It 
is  a  term  to  which  the  lay  mind  does  not  object  and  is  there- 
fore one  which  is  used  indiscriminately  to  include  many  types 
of  mental  disorder.  This,  of  course,  is  wrong,  and  the  wise 
physician  will  not  make  his  diagnosis  in  such  a  loose  way. 
For  the  sake  of  convenience  the  writer  has  described  neur- 
asthenia and  chronic  nerve  exhaustion  under  the  same  head 
as  the  conditions  are  closely  allied.  Hysteria  is  sometimes 
confused  with  neurasthenia,  but  the  former  has  definite 
symptoms  and  unless  they  are  present  such  a  diagnosis  should 
not  be  made.  The  depression  of  neurasthenia  is  at  times 
mistaken  for  that  of  melancholia,  but  this  should  not  occur 
as  the  whole  history  is  different  and  even  the  nature  of  the 
depression  varies.  The  early  stages  of  general  paralysis  may 
closely  resemble  nerve  exhaustion.  The  eye  reflexes  must  be 
carefully  examined,  and  if  an  accurate  diagnosis  is  of  import- 
ance the  cerebro-spinal  fluid  should  be  tested.  In  any  case 
in  which  the  head  symptoms  are  severe,  care  must  be  taken 
to  exclude  organic  disease  before  neurasthenia  is  diagnosed. 
For  it  must  be  borne  in  mind  that  nerve  exhaustion  states 
may  be  associated  with  organic  disease. 

Prognosis. — The  prognosis  varies  greatly  in  different  cases. 
As  a  general  rule  youths  who  break  down  before  twenty  years 
of  age  recover,  but  have  many  relapses.  Men  and  women  who 
develop  nerve  exhaustion  after  fifty  years  of  age  seldom  entirely 
regain  their  former  vigour.  The  most  hopeful  patients  are 
those  who  become  neurasthenic  from  some  definite  cause  during 
the  prime  of  life  ;  if  they  are  willing  to  follow  carefully  the 
treatment  laid  down,  their  efforts  may  be  rewarded  by  total 
recovery.  There  is,  it  should  be  added,  a  class  of  persons  who 
seem  by  mental  and  moral  qualities  somewhat  prone  to  nerve 
exhaustion.  They  are  keen  and  energetic  workers  and  of  a 
temperament  which  exposes  them  to  further  imposition  in  the 
matter  of  work  by  the  selfish  and  idle.  Many  years  of  close 
and  sometimes  unnecessary  work  may  dispose  such  persons  to 
become  neurasthenic.  In  these  cases,  when  the  nervous  failure 
comes,  it  is  often  serious.  Neurasthenia  often  begins  gradually 
with  some  preliminary  indications  of  exhaustion.  Where  this 
is  the  case,  the  sufferer  should  be  warned  to  devote  less  time 
to  work  and  more  to  food  and  rest. 


NERVE  EXHAUSTION  AND  NEURASTHENIA  259 

Pathology. — Nothing  is  definitely  known  as  to  the  patho- 
logy of  this  condition.  Auto-intoxication  may  play  a  part  in 
its  production  and  this  view  would  be  favoured  by  the  close 
relation  of  neurasthenia  to  fatigue  states.  But  clearly  auto- 
intoxication cannot  be  the  entire  cause  and  we  must  wait 
until  further  investigations  throw  more  light  on  the  subject. 

Treatment. — Nerve  exhaustion  can  no  doubt  be  prevented  in 
a  large  majority  of  cases  and  it  is  to  this  end  that  the  physi- 
cian must  direct  his  energies.  As  this  disorder  develops  slowly, 
there  is  usually  plenty  of  time  to  warn  the  patient  to  amend 
his  ways.  Do  not  hesitate  to  state  in  clear  language  the 
risk  that  is  incurred  by  persistence  in  the  habits  which  have 
produced  the  condition.  A  habit  of  late  hours  must  be  ex- 
changed for  one  of  retiring  at  half-past  ten  ;  work  to  the 
neglect  of  meals  must  be  stopped  and  brought  within  due 
limits  ;  the  necessity  of  fresh  air  and  moderate  exercise  must 
be  insisted  upon,  where  it  has  been  overlooked  ;  athleticism  to 
the  extent  of  physical  exhaustion  must  be  brought  within  due 
bounds  ;  study  carried  to  excess  must  be  moderated.  Work 
and  exercise  must  be  adjusted  and  faulty  living  corrected. 

Further,  the  physician  must  point  out  that,  since  the  dis- 
order results  from  an  extended  period  of  ill-regulated  living, 
it  will  require  a  long  period  of  care  and  treatment  to 
re-establish  the  health.  When  once  the  neurasthenic  con- 
dition has  declared  itself,  the  treatment  must  be  that  of  rest 
and  good  feeding.  Travelling  is  to  be  deprecated  until  the 
nervous  energy  has  shown  signs  of  recovery.  Physical  ex- 
haustion will  exaggerate  the  symptoms  ;  many  a  man  has 
aggravated  a  neurasthenic  condition  by  travelling  or  taking 
hard  exercise.  Bed  is  the  proper  place  for  a  neurasthenic  ; 
he  should  remain  there  for  several  weeks.  Best  in  bed  will 
often  save  the  patient  months  of  trouble  later.  Nevertheless 
it  must  be  borne  in  mind  that  the  young  neurasthenic  is  very 
liable  to  contract  the  bed  habit.  Hydrotherapeutics  are  also 
beneficial  in  some  cases  and  a  course  of  treatment  by  mineral 
waters  may  be  given  with  advantage.  Massage  is  not  advised  in 
the  early  stages  ;  it  frequently  causes  fatigue  without  any  com- 
mensurate benefit.  Active  gymnastics  and  exercises  usually 
increase  the  nervous  symptoms,  but  relaxation  exercises  as 
described  later  should  be  taught  as  they  frequently  give  great 
relief.     Many  patients  recover  more  rapidly  when  in  the  care  of 


260  PSYCHOLOGICAL  MEDICINE 

strangers  than  in  their  own  homes.  Plenty  of  milk  and  eggs 
should  be  taken  ;  alcohol  is  not  required,  but  stout  is  often 
taken  with  advantage.  The  personal  cheerfulness  and  hope- 
fulness of  the  physician  will  go  a  very  long  way  in  assisting 
a  neurasthenic  to  recover.  Drugs  should  be  given  if  indicated 
by  any  symptoms  such  as  aniaemia  or  gastritis.  Insomnia  must 
be  treated  and  until  the  sleep  returns  the  patient  cannot  be 
looked  upon  as  convalescent.  The  patient  should  have  abun- 
dant fresh  air  ;  in  the  summer  weather  he  should  live  out  of 
doors  and  even  in  bad  w^eather  verandas  should  be  used.  The 
writer  advises  one  dose  of  five  grains  of  potassium  bromide 
a  day  to  be  taken  regularly  for  some  years. 

Anxiety  Neueosis 

This  is  a  term  used  by  Freud.  Formerly  these  cases  were 
included  amongst  the  nerve  exhaustion  states.  It  is  a  con- 
dition in  which  the  patient  is  in  a  constant  state  of  fear  without 
any  obvious  cause.  The  degree  of  terror  varies  greatly  and  it 
is  always  associated  with  physical  symptoms,  the  more  impor- 
tant of  which  are  tachycardia,  altered  respiration,  perspiration 
or  flushing,  giddiness  and  tremors  ;  distm'bed  sleep  and  terrify- 
ing dreams  may  also  be  amongst  the  symptoms  complained  of 
by  the  patient.  Freud  regards  the  condition  as  due  to  an 
accumulation  of  mental  excitement  which  at  the  moment  has  no 
efficient  outlet.  Further  he  considers  that  this  excitement  is 
probably  always  of  a  sexual  nature. 

Acute  Hallucinatory  Insanity 

This  type  of  mental  disorder  is  that  described  by  Kraepelin 
mider  the  name  of  Exhaustion  Psychoses,  which  he  subdivides 
into  two  classes,  namely.  Collapse  Delirium  and  Acute  Con- 
fusional  Insanity  (Amentia).  The  distinction  involved  in  this 
subdivision  seems  almost  too  fine  for  practical  purposes  and 
the  cases  will  be  here  treated  under  one  head.  This  condition 
is  an  extreme  form  of  exhaustion  and  is  commonly  observed 
during  or  after  febrile  disorders  such  as  influenza,  typhoid, 
acute  rheumatism,  scarlet  fever,  septicoemia  after  severe 
haemorrhages,  surgical  operations,  childbirth,  excessive  mental 


ACUTE  HALLUCINATORY  INSANITY  261 

or  physical  fatigue  or  worry  ;   also  as  a  result  of  malnutrition 
of  the  cerebral  cortex  brought  about  by  anaemia. 

Mental  Symptoms. — The  illness  usually  begins  by  a  loss  of 
power  of  attention,  accompanied  by  restlessness  and  irrita- 
bihty.  Sleep  is  uncertain  and  becomes  progressively  worse. 
After  a  few  days  a  certain  amount  of  mental  confusion  will 
be  observed,  and  this  may  be  evidenced  by  the  tendency  of 
the  patient  to  mistake  the  identity  of  those  about  him.  The 
memory  is  noted  to  be  uncertain  and  he  fails  to  register  passing 
events,  and  when  the  illness  becomes  estabHshed,  the  memory 
is  very  bad.  The  rapid  change  in  the  mental  state  of  the 
patient  is  very  characteristic  of  this  illness.  One  hour  he  will 
be  apparently  well,  whilst  a  few  moments  later  the  mind  will 
show  mai'ked  signs  of  confusion.  Sensation  rapidty  becomes 
disordered  and  hallucinations  of  every  sense  may  appear. 
Birds  may  be  seen  %ing  about  the  room  and  insects  crawlmg ' 
over  the  bed.  The  food  lasbj  be  suspected  of  containing 
poison ;  and  a  complaint  may  be  made  of  the  presence  of  foul 
gases  in  the  bedroom.  The  patient  soon  becomes  disorientated 
both  as  to  time  and  place.  Ideational  inertia  is  common. 
Imperception  is  often  present  and  the  patient  will  fail  to  under- 
stand the  meaning  of  words  said  to  him  or  of  objects  shown. 
It  is  with  this  failure  to  perceive  and  with  disordered  sensation 
that  delusions  arise.  Judgment  is  disturbed  and  everything 
is  misinterpreted.  The  delusions  are  so  varied  that  it  would 
be  impossible  to  recite  them  all  here.  Eestlessness  may 
become  more  and  more  a  prominent  symptom,  and  in  severe 
cases  it  is  impossible  to  keep  the  patient  in  bed.  The  move- 
ments are  not  so  wide  and  rapid  as  in  maniacal- depressive 
mental  disorder.  The  emotional  state  may  be  either  one  of 
cheerfulness  or  depression,  but  the  latter  is  the  more  common, 
and  in  some  cases  it  may  vary  on  different  days.  Active 
attention  being  in  abeyance,  these  patients  are  always  intensely 
impulsive.  They  will  suddenly  jump  out  of  bed  and  make  a 
dash  for  the  door  or  window,  and  for  this  reason  they  must  be 
regarded  as  acutely  suicidal.  Speech  is  usually  incoherent 
as  the  patient,  being  inattentive  to  those  about  him,  merely 
reacts  to  his  own  thoughts.  Fears  are  common  and  in 
some  cases  the  frightened  state  makes  him  difficult  to  control. 
Food  is  often  refused  and  tube-feeding  may  become  necessary. 


262  PSYCHOLOGICAL  MEDICINE 

In  the  mild  cases  consciousness  may  not  be  very  clouded. 
During  the  acute  stages  of  the  illness  patients  pass  everything 
under  them.  Masturbation  may  be  a  prominent  symptom, 
and  when  present  it  may  seriously  prejudice  the  chances  of 
recovery  owing  to  the  further  exhaustion  it  produces. 

Physical  Symptoms. — The  general  health  is  poor  and  the 
patient  usually  looks  ill.  The  body  weight  falls.  The  appetite 
is  bad.  The  tongue  is  dry  and  as  the  disease  advances  sordes 
may  appear  about  the  hps  and  mouth.  The  bowels  are  con- 
stipated and  the  urine  scanty.  Tremors  may  be  observed  in 
the  hands  and  facial  muscles.  The  pupils  are  widely  dilated 
but  react  normally  to  hght  and  accommodation.  The  pulse  is  of 
very  low  tension  and  may  be  frequent  or  slow.  The  tempera- 
ture is  at  first  sub-normal  but  later  may  be  raised  if  the  patient 
passes  into  a  low  delirious  condition.  Stoddart  has  noted  that 
peripheral  anaesthesia  is  invariably  present  during  the  early 
stages  of  the  illness. 

Com^se. — Under  treatment  and  with  careful  attention  to 
food,  sleep,  and  bowels,  the  patient  slowly  begins  to  recover 
after  a  few  weeks  or  months.  The  restlessness  becomes  less 
acute  ;  the  delusions  and  hallucinations  disappear,  at  first  for  a 
few  hours  at  a  time  and  ultimately  altogether.  Consciousness 
is  less  clouded  and  questions  will  be  more  readily  answered. 
It  will  nevertheless  be  noticed  that  for  some  weeks  the  patient 
fatigues  very  rapidly,  a  point  which  should  be  borne  in  mind 
when  the  advisability  of  visits  from  friends  is  under  considera- 
tion. There  may  be  a  period  of  mental  confusion  of  the  stu- 
porose  type.  Irritability  is  a  symptom  which  usually  persists 
for  several  weeks  after  convalescence  is  estabhshed.  Attempts 
at  letter-writing  will  end  in  failure  ;  it  is  therefore  wise  to 
forbid  such  efforts.  Sleep  returns  by  degrees,  but  it  may  be 
several  months  before  it  is  good  either  in  quality  or  quantity. 

Diagnosis. — As  this  disorder  is  one  that  develops  during 
the  weeks  when  a  patient  is  convalescing  from  an  acute  illness, 
or  after  some  special  stress,  the  diagnosis  from  other  forms  of 
mental  disorder  is  not,  as  a  rule,  difficult.  The  chief  danger 
lies  in  the  condition  being  overlooked  or  misunderstood,  and 
in  this  way  valuable  weeks  may  be  lost  before  proper  treatment 
is  begun.  The  mental  disorder  may  at  first  be  so  shght  that  it  is 
put  down  to  general  physical  weakness  ;    and  even  when  the 


ACUTE  HALLUCINATORY  INSANITY  263 

symptoms  become  clearly  marked,  they  are  apt  to  be  explained 
away  by  the  physician,  if  he  is  not  fully  conversant  with  this 
special  malady. 

Prognosis. — The  prognosis  is  as  a  rule  good,  and  only  about  ten 
per  cent,  become  weak-minded.  A  certain  number  die  during 
the  early  stages  of  the  illness.  Eecovery,  when  it  takes  place, 
is  usually  four  to  six  months  from  the  onset  of  the  illness, 
but  in  some  cases  it  may  be  delayed  up  to  twelve  or  eighteen 
months. 

Pathology  and  Morbid  Anatomy  Changes. — In  those  cases 
where  autopsies  have  been  made,  chromatolysis  of  the  nerve- 
cells  of  the  brain  has  been  found  ;  this  change  is,  however, 
by  no  means  pathognomonic,  as  it  occurs  in  many  other 
diseases.  The  changes  in  the  blood  in  this  condition  have  been 
referred  to  in  the  chapter  on  General  Symptomatology.  The 
writer  is  inclined  to  think  that  acute  hallucinatory  insanity  is 
•brought  about  by  a  defective  circulation  and  a  general  hyper- 
sensitivity of  the  nervous  system. 

Treatment. — The  patient  should  be  kept  in  bed,  and  if  he  is 
in  the  ward  of  a  hospital  at  the  time  of  the  attack,  he  should 
be  moved  into  a  private  room  and  isolated.  Absolute  quiet 
is  necessary ;  visits  from  relatives  should  be  interdicted. 
Food  should  be  of  a  light  and  nourishing  nature  ;  if  solids 
are  refused,  a  plentiful  liquid  diet  must  be  administered. 
Nourishment  should  be  given  every  three  hours  during  the 
day  and  also  throughout  the  night  if  the  patient  is  awake. 
Alcohol  should  be  avoided  if  possible  ;  but  if  there  is  great 
weakness,  or  if  collapse  threatens,  brandy  or  champagne  must 
be  given.  If  there  is  great  restlessness  and  the  pulse  is  rapid 
and  low-tensioned,  infusion  of  normal  salt  solution  into  the 
subcutaneous  tissues  of  the  chest  or  back  is  excellent  treat- 
ment and  quickly  relieves  the  acute  symptoms.  Only  one 
pint  should  be  infused  at  a  time.  Hypnotics  should  be  given 
if  required.  Warm  baths  are  most  valuable  in  some  cases 
in  correcting  insomnia.  Acute  excitement  may  sometimes 
be  relieved  by  y^  gr.  hydrobromate  of  hyoscine.  Tube  feed- 
ing may  become  necessary,  and  it  is  very  important  not  to 
delay  this  too  long  if  insufficient  nourishment  is  being  given. 
If  the  patient  is  in  a  very  weak  state,  with  a  feeble  pulse,  opium 
is  indicated,  and  a  grain  pill  or  fifteen  minims  of  the  tincture 


264  PSYCHOLOGICAL  MEDICINE 

every  four  hours  frequently  acts  with  remarkable  effect  and 
brings  about  a  general  improvement  in  the  physical  and  mental 
condition. 

When  convalescence  has  set  in,  it  is  incumbent  on  the 
physician  to  lay  down  very  stringent  rules  as  to  the  visits  of 
relatives  and  others.  An  injudicious  visitor  may  do  great 
harm  and  cause  a  serious  relapse.  Interviews  should  not 
exceed  five  minutes  in  length,  and  no  worrying  topics  should  be 
broached.  The  slower  and  quieter  the  character  of  the  earlier 
stages  of  convalescence,  the  better  is  the  result  ;  it  is  very 
unwise  to  try  to  hurry  the  patient  in  the  foolish  attempt  to 
make  a  rapid  cure.  The  building-up  process  is  of  necessity 
slow,  and  it  must  take  several  months  before  all  the  bodily 
functions  are  working  normally  and  proper  sleep  has  returned. 
The  body  weight  is  a  useful  index  as  to  the  progress  of  the  case, 
as  this  ought  slowly  and  steadily  to  rise  ;  as  a  rule,  by  the 
time  health  is  established  the  patient  weighs  considerably-, 
more  than  he  did  before  his  illness.  This  need  cause  no  alarm, 
as  the  weight  nearly  always  returns  to  normal  when  the  daily 
routine  of  life  again  begins.  Throughout  the  attack  the  bowels 
must  receive  careful  attention  and  the  patient  must  be  warned 
to  avoid  constipation  in  the  future.  If  there  is  much  anaemia 
this  should  be  corrected  by  the  administration  of  iron  and 
arsenic.  When  exercise  is  taken  it  must  be  in  moderation,  as 
physical  exhaustion  is  always  reflected  in  an  increase  of  the 
mental  symptoms. 


265 


CHAPTEE  XVI 

GENERAL  NEUROSES:   EPILEPSY  AND   INSANITY,   HYSTERIA 
AND  INSANITY,   TRAUMATIC  NEUROSES 

Epilepsy  and  Insanity 

Epilepsy  and  insanity  are  closely  allied.  The  factors  which 
produce  the  one  may  also  produce  the  other.  A  neurotic 
parent  may  have  one  child  who  is  epileptic  and  another  who 
is  insane.  There  may  be  epilepsy  in  one  generation  and  insanity 
in  the  next,  or  vice  versa.  About  fifteen  per  cent,  of  all  epi- 
leptic individuals  become  insane  but,  apart  from  actual  insanity, 
epilepsy  frequently  produces  varying  degrees  of  weak-minded- 
ness. On  the  other  hand,  a  person  may  have  epileptic  fits  for 
years  and  yet  never  show  any  marked  mental  disturbance. 
Petit  mal,  as  a  rule,  brings  about  a  general  failure  of  the 
intellectual  faculties  with  profound  loss  of  memory. 
I  etiology. — We  usually  find  a  neuropathic  inheritance  in 
more  than  fifty  per  cent,  of  all  cases  of  epilepsy.  Insanity  is 
commonly  found  in  the  parents  of  epileptics.  Epilepsy  begets 
epilepsy  and  we  frequently  find  an  epileptic  father  has  an 
epileptic  son.  Most  cases  of  epilepsy  begin  before  the  age  of 
twenty  and  epileptic  insanity  usually  develops  before  thirty- 
two.  When  epilepsy  develops  in  persons  between  forty  and 
fifty  years  of  age  it  may  be  a  complication  of  an  exhaustion 
state  and  if  treated  early  the  result  is  frequently  good.  Females 
suffer  from  epilepsy  to  a  somewhat  greater  extent  than  males. 
The  stresses  which  may  set  up  convulsions  in  predisposed  per- 
sons are  very  numerous.  At  dentition  they  are  very  common  ; 
emotional  disturbance,  such  as  fright,  may  also  give  rise  to 
an  epileptic  seizure.  Usually  the  more  marked  the  nervous 
instabihty,  the  less  the  stress  required  to  produce  a  convulsion. 
An  acute  specific  fever  may  be  the  determining  factor  ;  or  the 
exciting  cause  may  be  reflex  in  origin,  as  for  example  intes- 


266  PSYCHOLOGICAL  MEDICINE 

tinal  worms.  A  history  of  heacl-injury  is  found  in  a  small 
proportion  of  cases.  Finally,  it  is  by  no  means  uncommon 
to  find  epilepsy  in  the  female  first  beginning  about  the  age 
of  puberty. 

On  the  other  hand,  in  a  fair  proportion  of  cases  no  exciting 
causes  can  be  found,  but  when  present  they  are  varied  and 
numerous  and  act  with  greater  effect  upon  the  neurotic  indi- 
vidual. Once  a  convulsion  has  taken  place,  there  is  a  tendency 
to  a  recurrence,  and  with  each  recurring  seizure  this  tendency 
becomes  greater,  until  finally  a  habit  is  formed.  The  nerve- 
storms  may  be  slight,  in  which  case  there  is  only  a  momentary 
loss  of  consciousness ;  or  it  may  be  greater,  when  the  whole 
of  the  motor  centres  are  involved,  and  there  is  a  convulsive 
seizure.  Between  these  extremes  there  are  many  varying 
degrees.  Gross  brain  disease  or  trauma  may  at  times  cause 
epileptic  convulsions 

Varieties  of  Insanity  associated  with  Epilepsy. — Epilepsy 
may  lead  to  many  forms  of  mental  disorder.  (1)  In  early 
life  repeated  convulsions  may  seriously  interfere  with  mental 
development    and  e'pile'ptic    idiocy  or  imhecility  may   result. 

(2)  A  second  class  to  be  considered  comprises  those  forms 
of  mental  disorder  which  precede  a  fit,  fjre-e'pilefiic  insanity. 

(3)  Some  authorities  believe  that  a  fit  can  be  replaced  by  some 
mental  disturbance,  and  others  consider  that  the  seizure  is  so 
slight  that  it  is  overlooked  in  the  presence  of  the  more  marked 
mental  symptoms.  This  condition  is  known  as  mashed  e-pilej)sy 
{^pilepsie  larvee).  (4)  Mental  disturbances,  often  of  a  very 
severe  type,  may  occur  immediately  after  a  lit,  'post  epilepiic 
mental  disorder.  (5)  The  most  common  form  of  mental  disease 
met  with  in  association  with  epilepsy  is  known  as  chronic 
epileptic  insanity.  (6)  Finally,  the  epileptic  may  suffer  from 
temporary  attacks  of  mental  disorder  such  as  may  occur  in 
non-epileptic  persons,  temporary  insanity. 

Symptoms  exhibited  under  the  above  Varieties  of  Mental 
Disorder. — (1)  Epileptic  Idiocy  and  Imbecility  are  terms  used 
to  indicate  those  cases  in  which  early  epilepsy  has  seriously 
interfered  with  the  mental  growth  of  the  individual.  Idiocy 
and  imbecility  are  relative  terms,  the  former  indicating  a 
greater  degree  of  weak-mindedness  than  the  latter.  Epilepsy 
is  one  of  the  commonest  causes  of  idiocy  and  as  such  is  dealt 
with  in  a  subsequent  chapter.     As  has  already  been  observed. 


EPILEPSY  AND  INSANITY  267 

the  exciting  cause  of  the  first  seizure  may  be  of  almost  any 
kind.  In  epileptic  idiots  the  seizures  may  be  either  major  or 
minor  in  character,  and  the  latter  are  often  more  damaging  than 
the  former  to  the  nervous  system.  Children  suffering  from 
epileptic  idiocy  are  usually  very  impulsive  and  irritable,  and  if 
not  watched,  may  seriously  injure  any  younger  children  with 
whom  they  may  be  associated.  If  the  fits  continue  there  is 
a  steady  mental  deterioration  and  education  is  exceedingly 
difficult.  It  should,  however,  be  noted  that  a  child  may 
have  convulsions  for  some  years  without  showing  any  marked 
intellectual  degeneration.  If  treatment  is  successful,  the 
mental  condition  rapidly  improves. 

(2)  Pre-e'pileptic  Insanity. — -The  epileptic  aura,  if  present, 
is  the  warning  which  the  patient  receives.  Though  it  usually 
immediately  precedes  the  seizure,  in  some  cases  it  may  last 
for  hours  or  even  days.  The  aura  may  be  of  any  kind  ;  it 
may  be  some  alteration  of  sensation,  such  as  tingling  or  pricking 
sensations  in  the  skin.  Vertigo  is  very  common  and  also 
epigastric  or  throat  sensations.  More  rarely  the  motor  system 
is  the  one  affected.  A  patient  may  move  round  in  a  circle,  or 
there  may  be  a  feeling  of  cramp  in  some  group  of  muscles. 
Hallucinations  and  illusions  of  sight  and  hearing  are  often  met 
with  ;  olfactory  and  gustatory  disturbances  are  less  frequent. 
There  are  many  other  types  of  warning,  but  space  does  not 
permit  a  description  here.  It  is,  however,  important  to  observe 
that  the  aura  may  be  psychical  in  character.  Sounds  may 
terrify  a  patient,  or  '  voices  '  may  direct  him  to  do  some  foolish 
act.  Delusions  may  be  expressed  and  false  accusations  may 
be  made  by  persons  in  the  pre-epileptic  state.  The  medico- 
legal aspect  ought  to  be  remembered,  as  apart  from  actual 
violence  patients  may  make  serious  charges  against  others, 
believing  that  they  have  been  criminally  assaulted  or  insulted 
in  other  ways.  Offences  against  the  moral  code  of  laws  may 
be  unconsciously  performed  during  this  pre-epileptic  dreamy 
state.  Violent  outbursts  of  acute  mania  may  precede  an 
epileptic  seizure  by  some  hours  or  days  ;  the  excitement  is 
usually  very  intense  and  commonly  there  is  refusal  of  food.  In 
other  cases  there  is  depression  preceding  a  fit,  with  a  general 
feeling  of  malaise,  and  sometimes  a  tendency  to  be  suspicious 
and  quarrelsome. 

(3)  Masked  Eyilepsy. — This  is  a  term  used  to  denote  those 


268  PSYCHOLOGICAL  MEDICINE 

cases  ill  which  there  is  no  noticeable  seizure.  The  fit  is  said 
to  be  replaced  by  some  other  condition,  such  as  an  outburst 
of  excitement*  Cases  of  automatism  also  come  under  this 
head.  Authorities  have  differed  as  to  whether  the  fit  is 
actually  replaced  ;  many  believe  that  it  is  usually  present  but 
so  transient  as  to  be  overlooked.  This  class  of  automatism 
is  sometimes  called  psychic  epilepsy  and  may  last  a  varying 
time,  from  a  few  hom^s  to  several  weeks.  These  patients  may 
behave  in  an  apparently  normal  manner,  or  they  may  perform 
complex  actions  of  which  they  remember  nothing  when  they 
return  to  the  normal  state  again.  In  this  state  I  have  known 
a  man  to  travel  to  New  York  instead  of  going  to  his  office,  and 
when  he  awoke  at  the  end  of  the  voyage  he  was  greatly  dis- 
turbed to  find  where  he  was  and  could  not  remember  how 
he  had  got  there.  Eecovery  from  these  attacks  is  frequentl}' 
sudden,  and  some  patients  state  that  they  feel  something  give 
way  in  their  heads.  The  memory  is  not  always  completely 
lost,  and  the  patient  may  be  able  to  give  some  account  of  what 
he  has  been  doing. 

(4)  Post-e'pile'ptic  mental  disorders  are  of  various  kinds, 
and  they  have  a  very  important  medico-legal  aspect.  Prob- 
ably epileptics  are  more  homicidal  during  this  stage  than 
in  any  other.  The  ordinary  coma  which  usually  follows  a  fit 
may  be  absent  and  be  replaced  by  a  period  of  automatism, 
fost-efih'ptic  automatism.  Fully  organised  and  definite  auto- 
matic acts  may  also  follow  major  or  minor  seizures  but 
more  commonly  the  minor.  These  patients  are  confused,  and 
wander  aimlessly  about  ;  they  even  fail  to  recognise  their 
immediate  relatives.  Criminal  acts  of  almost  every  kind  m.ay 
be  openly  committed  ;  among  the  most  common  are  arson, 
homicidal  attacks,  sexual  assaults,  and  indecent  exposure. 
Simpler  forms  of  automatism  are  frequently  observed  ;  for 
example,  a  patient  will  fold  up  his  clothes  or  tidy  a  room.  On 
recovery  he  rarely  remembers  anything  of  what  has  happened. 

Individuals  have  wandered  long  distances  from  their  homes 
during  the  stage  of  automatism,  and  on  regaining  consciousness 
have  been  astonished  to  find  themselves  in  another  town. 
These  patients  are  usually  totally  unable  to  account  for  their 
conduct  during  the  period  of  automatism  ;  they  will  say  that 
they  can  remember  up  to  a  certain  time  on  a  certain  day. 


EPILEPSY  AND  INSANITY  269 

and  then  comos  a  gap,  over  which  they  cannot  bridge.  Often 
the  actions  performed  during  the  period  of  automatism  show 
an  entire  absence  of  motive  ;  it  may,  however,  be  possible  to 
read  motives  into  some  actions.  In  cases  of  crime  committed 
in  a  post- epileptic  condition,  there  is  usually  no  attempt  at 
concealment  at  the  time  of  perpetration  ;  but,  with  returning 
consciousness,  fear  may  come,  and  efforts  be  made  at  con- 
cealment. Epileptics  who  have  had  repeated  fits  which  have 
been  followed  by  automatic  acts,  may  learn  the  danger  of 
the  condition  ;  and,  if  they  have  any  warning  of  the  approach 
of  seizm^e,  they  may  ask  persons  near  them  to  leave.  Refusal 
to  obey  such  a  request  has  been  known  to  be  followed  by 
serious  results.  The  automatic  stage  may  last  for  a  few 
moments  only  or  may  continue  for  an  hour  or  two  or  longer. 
Some  patients  are  intensely  suspicious  for  some  time  after 
seizure  and  will  strongly  resent  any  interference.  There  is 
no  doubt  that  a  number  of  murders  have  been  committed 
during  the  period  of  automatism  following  a  sHght  fit.  It  is 
by  no  means  easy  to  convince  the  lay  mind  that  acts  of  this 
kind  cannot  be  regarded  as  intentional  homicide.  This  is 
especially  the  case  when  the  seizures  were  so  slight  that  they 
had  been  overlooked.  The  physician  must  largely  rely  on 
the  former  history  of  the  patient,  the  absence  of  adequate 
motive,  and  the  manner  in  which  the  act  was  committed.  A 
history  that  the  person  has  had  similar  attacks  during  which 
he  has  done  extraordinary  things  is  a  point  of  great  importance. 

A  violent  attack  of  mania  is  another  form  of  mental  dis- 
order which  may  follow  an  epileptic  seizure.  This  post- 
epileptic excitement  is  often  so  intense  that  it  has  been  named 
ejpih'ptic  furor.  In  these  cases  there  is  usually  no  coma,  the 
patient  passing  at  once  into  this  maniacal  condition  ;  at  times, 
however,  the  excitement  follows  a  period  of  sleep.  A  patient 
in  this  condition  will  bite  and  scratch  and  make  violent  and 
even  homicidal  assaults  ;  a  female  may  try  to  tear  out  the 
hair  of  the  nurses.  The  symptoms  are  those  of  mania  of  a 
very  acute  kind,  and  of  all  forms  of  mania  this  is  the  most 
violent.  Fortmiately  it  is  as  a  rule  quite  transient,  passing 
off  after  a  few  hours. 

In  a  smaller  proportion  of  cases  a  period  of  depression  may 
follow  the  fit.     As  a  rule  there  are  delusions,  especially  of 


270  PSYCHOLOGICAL  MEDICINE 

persecution  ;  the  epileptic  may  revenge  himself  on  those  near 
to  him  and  in  some  cases  may  attempt  self-injmy.  Enough 
has  been  said  to  show  that  the  post-epileptic  stage  is  fre- 
quently a  very  dangerous  one  for  those  who  may  be  associated 
with  the  patient,  for  his  confusion  of  mind  may  lead  him  to 
make  either  false  accusations  or  definite  assaults. 

(5)  Chronic  Eyileftic  Insanity  may  be  looked  upon  as  the 
true  epileptic  insanity.  Some  persons,  as  has  been  observed, 
may  suffer  from  epilepsy  and  yet  show  no  marked  mental 
change,  or  may  even  be  capable  of  doing  brilliant  work.  This, 
however,  must  be  regarded  as  exceptional ;  the  tendency  of 
epilepsy  is  towards  mental  deterioration,  more  especially  if  the 
seizures  have  begun  in  early  hfe.  Memory  begins  to  fail  and 
in  time  shows  signs  of  serious  impairment.  Emotional  dis- 
turbances of  all  kinds  are  frequent.  Outbursts  of  anger  and 
passion,  exaltation  and  excitement,  alternate  with  periods  of 
misery  and  gloom.  The  judgment  becomes  warped  and  un- 
reliable. The  patient  will  speak  highly  of  his  intellectual 
ability,  although  his  mental  capacity  is  steadily  faihng.  He 
is  often  cruel,  and  tends  to  become  a  moral  pervert.  He 
will  He  freely,  and  eventually  no  rehance  can  be  placed  upon 
any  of  his  statements. 

Many  patients  of  this  class  will  spend  much  time  in  reading 
the  Bible  and  trying  to  convert  others.  They  are  rehgiose 
rather  than  rehgious  ;  in  words  they  profess  much,  but  their 
actions  belie  them.  Their  whole  character  is  changed  and 
any  former  altruistic  attributes  are  lost.  Self  is  their  god  ; 
they  are  egotistical  and  boastful.  They  become  cunning  and 
treacherous  and  may  revenge  themselves  upon  the  infirm 
and  weak,  and  in  the  face  of  accusation  deny  all  knowledge 
and  emphasise  the  denial  with  Bibhcal  quotations.  Occasionally 
they  show  great  acuteness  of  memory,  and  even  capacity  for 
work  ;  but,  as  time  passes,  these  embers  of  remaining  power 
bum  out  ;  mental  degeneration  becomes  more  and  more 
marked,  until  there  is  nothing  left  but  the  lower  instincts  in 
their  most  degraded  forms.  Sexual  excitement  is  common, 
and  imless  carefully  watched,  patients  of  this  class  will 
practise  every  form  of  sexual  vice. 

(6)  Temporary  Insanity. — Epileptics,  in  common  with  the 
rest  of  humanity,  may  suffer  from  attacks  of  mental  disorder; 


EPILEPSY  AND  INSANITY  271 

and,  for  want  of  a  better  term,  we  shall  speak  of  the  condition 
as  one  of  temporary  insanity.  An  epileptic  may  suffer  from 
melancholia  and  may  recover  in  the  usual  way  ;  the  attack 
may  be  an  isolated  one,  or  he  may  have  recurrence  of  the 
condition.  We  do  not  need  to  go  further  into  this  subject,  as 
such  illnesses  in  every  way  resemble  acute  mania  and  melan- 
choha,  as  described  in  a  former  chapter. 

Physical  Symptoms. — The  physical  health  suffers  to  some 
extent.  There  is  a  tendency  to  nutritional  disturbances,  and 
the  body  weight  often  falls.  The  gastro-intestinal  system  is 
usually  disordered  ;  the  tongue  is  furred  and  the  bowels  con- 
stipated.    Sleep  is  disturbed  and  unrefreshing. 

The  seizures  are  the  most  important  symptoms.  These  may 
be  of  two  kinds  :  (1)  Grand  Mai,  or  major  epilepsy  ;  and  (2) 
Petit  Mai,  or  minor  epilepsy.  (1)  With  the  former  there  may 
be  an  aura  or  warning,  but  this  is  usually  followed  at  once  by 
loss  of  consciousness.  The  patient  falls  helplessly  to  the  ground 
in  a  condition  of  tonic  convulsions.  Commonly  there  is  a  cry 
due  to  the  forcible  contraction  of  the  chest  muscles  driving 
air  from  the  lungs  through  the  glottis.  In  about  thirty  or 
forty  seconds  the  tonic  spasm  gives  way  and  is  replaced  by 
the  clonic  convulsion,  the  result  of  alternating  contraction  and 
relaxation  of  the  muscles.  It  is  not  necessary  in  a  work  of 
this  kind  to  enter  into  the  minute  particulars  of  these  seizures, 
as  they  are  dealt  with  in  text-books  on  general  medicine. 
Suffice  it  to  say  that  as  a  rule  consciousness  gradually  returns 
after  a  period  of  coma  or  sleep,  though  at  times  the  latter  may 
be  absent.  It  is  usual  for  a  seizure  to  occur  singly,  but  there 
may  be  a  succession  or  group  of  seizures  numbering  up  to  a 
hundred  or  more.  When  the  seizures  occur  in  series,  con- 
sciousness does  not  always  return  during  the  intervals.  The 
condition  is  known  as  status  ejpiU'pticus  and  may  terminate 
fatally. 

(2)  In  Petit  Mai,  or  minor  epilepsy,  there  is  a  brief  loss  of 
consciousness  lasting  for  a  few  seconds  to  about  half  a  minute. 
Convulsive  movements  are  as  a  rule  not  present  and  the 
patient  rarely  falls.  If  conversing  he  will  suddenly  stop  and 
his  face  will  lose  expression.  When  consciousness  returns  he 
may  at  once  continue  what  he  was  saying,  or  may  appear  some- 
what confused  and  inquire  what  he  was  talking  about.     These 


272  PSYCHOLOGICAL  MEDICINE 

minor  seizures  are  very  apt  to  recur  and  a  patient  may  have 
several  during  the  course  of  a  day.  The  mental  faculties 
generally  rapidly  fail ;  the  memory  becomes  very  uncertain 
and  there  is  an  increasing  incapacity  for  work.  If  definite 
mental  disorder  supervenes,  the  physical  health  may  suffer 
more  seriously. 

Diagnosis. — The  diagnosis  of  epilepsy  is  not  always  easy, 
especially  when  the  seizures  are  of  the  'petit  mat  type.  To 
add  to  the  difficulty,  the  fits  may  always  occur  at  night.  In- 
quiry should  be  made  for  such  symptoms  as  the  unconscious 
emptying  of  the  bladder.  The  tongue  may  be  examined  for 
scars  of  former  injury.  Sudden  erratic  conduct  or  offences 
contrary  to  the  previous  character  of  the  individual  should 
always  suggest  epilepsy  to  the  physician.  In  such  cases 
instructions  for  closer  supervision  should  be  given.  In  the 
case  of  persons  in  early  life  it  is  at  times  difficult  to  distinguish 
between  some  hysterical  disorders  and  true  epilepsy.  To 
enable  distinction  to  be  rightly  drawn  it  must  be  remembered 
that  hysterical  disturbances  rarely,  if  ever,  take  place  when 
the  patient  is  alone,  and  that  they  are  commonly  set  up  by 
some  external  influences.  Assistance  may  also  be  derived 
from  the  way  in  which  the  patient  falls.  In  hysteria  the  fall 
does  not  betoken  the  helplessness  of  the  epileptic.  Again,  in 
hysteria  there  is  rarely  the  total  loss  of  expression  seen  in  the 
epileptic.  The  clonic  stage  is  not  so  complete  in  hysteria  as  in 
epilepsy,  for  instead  of  regular  contractions  there  are  irregular 
movements.  Finally,  in  the  place  of  coma  there  is  an  emotional 
display  interspersed  with  symbolic  and  grotesque  attitudes. 

If  there  is  merely  mental  confusion,  the  epileptic  condition 
may  be  mistaken  for  that  of  other  types  of  mental  disorder. 

In  later  life  true  epilepsy  has  to  be  distinguished  from  the 
epileptic  seizures  commonly  met  with  in  general  paralysis. 
Epilepsy  is  not  usually  of  such  late  development  as  dementia 
paralytica,  but  the  presence  or  absence  of  other  physical  signs 
must  determine  the  diagnosis.  The  pupils,  speech,  hand- 
writing, and  various  reflexes,  must  all  be  carefully  examined. 
Again,  the  onset  of  the  seizures  often  varies  in  character  in  the 
two  conditions,  and  the  general  paralytic  rarely  has  the  epi- 
leptic cry.  The  examination  of  the  cerebro-spinal  fluid  may 
decide  the  diagnosis. 


EPILEPSY  AND  INSAKITY  273 

Prognosis. — Major  epilepsy  is  a  more  curable  disorder  than 
the  minor  forms.  If  major  epilepsy  develops  in  early  adoles- 
cence, it  may  often  be  successfully  treated  and  the  epilepsy 
of  later  life  is  even  more  curable.  As  the  treatment  ex- 
tends over  three  years,  rhany  persons  after  a  time  neglect 
to  carry  out  the  instructions  given,  but  those  who  will  take 
the  trouble  are  often  rewarded  by  the  disappearance  of  the 
seizures.  Epilepsy  the  result  of  gross  brain  disease  is  incurable, 
and  practically  the  same  may  be  said  of  the  minor  forms  of 
the  disorder.  Status  epilepticus  is  a  serious  condition  and 
frequently  ends  fatally. 

Pathology  and  Morl)id  Anatomy. — There  is  no  doubt  that 
epilepsy  is  the  result  of  some  disorder  of  the  cerebral  cortex. 
There  are  many  theories  as  to  what  these  changes  really  are, 
but  at  the  present  time  nothing  is  definitely  known.  Hughlings 
Jackson  has  pointed  out  that,  as  unconsciousness  is  the  first 
and  may  be  the  only  symptom,  the  inference  is  that  the  dis- 
order is  in  the  highest  levels,  probably  in  the  frontal  area 
of  the  brain.  In  Jacksonian  epilepsy,  on  the  other  hand,  the 
earHest  symptom  is  usually  some  movement  or  twitching, 
showing  that  the  primary  irritation  is  in  the  motor  area. 
Hughlings  Jackson  further  suggests  that  in  epilepsy  the  fault 
lies  in  defects  of  nutrition,  and  not  primarily  in  the  nervous 
elements.  The  view  that  alteration  of  blood  supply  to  the 
cortex  must  be  held  responsible  for  producing  these  nerve 
storms  is  supported  by  other  observers.  Similar  convulsions 
can  be  produced  in  animals  by  intravenous  injection  of  drugs 
such  as  absinthe  and  ammonium  carbamate  ;  or  even  sudden 
and  extreme  anaemia  of  the  cortex  will  suffice. 

Ford  Eobertson  writes  :  ^  'It  is  now  maintained  by  the 
great  majority  of  those  who  have  made  special  study  of  the 
subject,  that  there  are  two  great  factors  in  the  pathogenesis 
of  the  disease  in  the  human  subject ;  namely,  (a)  a  special 
defect  of  cerebral  organisation  which  predisposes  to  the  epileptic 
discharge,  and  (&)  a  toxic  action  which  determines  the  discharge. 
Some  beHeve  that  the  toxins  act  directly  upon  the  nerve-cells 
of  the  cortex,  others  maintain  that  they  influence  these  elements 
indirectly  by  producing  cerebral  congestion,  or  cerebral  anaemia 
from  vaso-motor  spasm.' 

1  Pathology  of  Mental  Disease. 

18 


274  Psychological  medicine 

He  briefly  sums  up  the  present  position  of  knowledge  re- 
garding the  toxic  basis  of  epilepsy  as  follows  :    '  It  is  fully 
proved   that  the  fits   are  preceded   and   determined   by  the 
accuinulation  in  the  blood  of  certain  toxins,  the  exact  origin 
and  nature  of  wdiich  is  still  uncertain,  although  a  great  amount 
of  light  has  now  been  throw^n  upon  the  subject.     It  is  probable 
that  the  toxins  consist  of  various  substances,  and  that  they 
differ  considerably  in  individual  cases.     Krainsky  has,  however, 
obtained  very  strong  evidence  in  support  of  his  contention 
that  in  many  cases  the  essential  irritant  is  ammonium  car- 
bamate ;    he  appears  to  have  disproved  the  theory  of  Haig 
that  epilepsy  depends  upon  a  retention  of  uric  acid  in  the 
blood.     In  persons  who  are  subject  to  epilepsy,  metabolism 
tends  to  be  imperfect  ;    the  average  elimination  of  azotised 
products,   phosphoric   acids   and   chlorides,   is   below  normal 
in  the  inter- conclusive  periods  ;    there  is   diminished  excre 
tion  of  azotised  substances  in  the  prodromal  period  ;    after 
a  fit  there  is  increase  in  the  density  and  acidity  of  the  urine, 
and  in  the  quantity  of  all  the  regressive  products  of  meta- 
bolism contained  in  it  ;    the  urine  of  epileptics  is  constantly 
more    toxic    than    normal    urine    when    injected    into    lower 
animals  ;    the  toxicity  increases  in  the  period  immediately 
preceding  the  fit,   and   is   in  strict   relation  to  the   gi'avity 
of   concomitant   gastro-intestinal  disturbances  ;   after  the  fit 
the   urine   is   hyper-toxic  (Agostini).     The  formation   of   the 
toxins  is  greatly  favoured  by  gastro-intestinal  disturbances, 
which,  indeed,  are  able  to  determine  the  occurrence  of  fits  ; 
these  can  be  prevented,  or  gi-eatly  diminished  in  numbers,  by 
washing  out  the  stomach,  and  by  the  use  of  purgatives,  saline 
enemas,   etc.    (Agostini).     The   gastro-intestinal   disturbances 
consist   chiefly  in  the   occurrence   of   abnormal  putrefactive 
processes  in  the  contents    of  the    alimentary  canal.     It  has 
been  proved  that  before  a  fit  occm-s  there  is  an  increase  in 
the  excretion  of  ethereal  sulphates,  which  may  De  taken  as 
the  index  of  the  amount  of  putrefactive  change  occurring  in 
the  alimentary  canal  (Galante  and  Savini).     It  has  also  been 
shown  that  in  association  with  the  accumulation  of  toxins  in 
the  system,  and  in  the  anticipation  of  a  fit,  there  is  constantly 
a  diminution  in  the  alkalinity  of  the  blood  (Lui,  Charon,  and 
Briche).' 


EPILEPSY  AND  INSANITY  275 

John  Turner  has  pointed  out  the  presence  of  blood-clots 
which  stain  green  with  Macallum's  phenyl-hydrazin  reagent 
in  the  cortical  vessels.  He  states  that  he  found  this  clotting 
in  ninety  per  cent,  of  epileptic  brains  and  only  in  thirty-five 
per  cent,  of  control  brains. 

Clearly  all  the  work  of  the  present  time  goes  to  corroborate 
the  view  that  the  epileptic  convulsion  is  largely  dependent  upon 
some  vascular  disturbance  in  the  cerebral  cortex.  The  writer 
does  not  think  that  toxins  primarily  play  so  important  a  role 
as  is  suggested,  though  they  may  ultimately  prove  elements 
which  largely  contribute  towards  the  recurrence  of  a  fit. 
He  believes  that  in  som_e  neurotic  persons  there  are  areas  of 
the  vaso-motor  system  which  are  more  liable  to  reflex  disturb- 
ances than  others.  In  the  milder  forms  of  Eaynaud's  disease 
local  syncope  may  be  observed  to  occur  in  the  fingers,  hands, 
feet,  and  other  parts,  the  result  of  vaso-motor  spasm  in  iso- 
lated areas.  Probably  paroxysmal  heemoglobinuria  is  another 
example  of  this  same  condition.  But  apart  from  actual  disease 
there  is  no  doubt  that  certain  nervous  individuals  are  liable 
to  develop  localised  areas  of  coldness,  due  to  some  vaso-motor 
disturbance.  Sexual  congress  probably  supplies  us  with  an 
excellent  example.  During  coitus,  or  immediately  after, 
some  persons  have  general  rigors,  or  the  affected  parts  may 
be  limited  to  the  lower  extremities,  or  one  limb.  Again,  the 
sexual  orgasm  may  be  followed  by  a  definite  epileptic  fit,  and 
— another  point  of  importance — the  seizures  may  be  confined 
to  the  performance  of  the  sexual  act.  Do  not  these  observations 
throw  some  side-lights  on  the  origin  of  the  disorder  ?  The 
seizures  cannot  be  the  result  of  toxins  in  the  instances  last 
given.  No  doubt  toxins,  and  especially  those  derived  from  the 
gastro-intestinal  tract,  in  many  cases  do  play  a  very  important 
part  in  recurring  epilepsy,  but  the  writer  feels  that  the  role  they 
play  is  that  of  an  irritant  on  an  already  unstable  mechanism, 
and  that  other  reflex  disturbances  may  act  with  equal  potency. 
In  this  way  it  may  be  concluded  that  epilepsy  is  to  a  certain 
extent  accidental,  and  dependent  upon  an  unstable  condition 
of  the  vaso-motor  system  in  the  cortical  areas  of  the  brain ; 
and  further,  that  similar  instabihty  in  other  parts  of  the 
vascular  system  may  be  found,  the  effects  produced  depending 
upon  the  importance  of  the  areas  affected. 


276  PSYCHOLOGICAL  MEDICINE 

There  is  one  factor  to  which  the  writer  would  specially 
draw  attention,  and  that  is  the  general  hyper-sensitivity  and 
over- excitability  of  the  nervous  system  in  epileptic  persons. 
Now  this  condition  is  frequently  noticeable  some  years  before 
the  patient  has  a  fit,  and  the  writer  has  found  that  if  this  con- 
dition is  treated  in  children  by  giving  two  and  a  half  to  five 
grains  of  potassium  bromide  once  a  day  for  several  years 
epileptic  fits  may  be  prevented.  That  they  are  thus  held 
in  check  is  proved  by  the  result  if  the  treatment  is  \\dthdrawn, 
viz.,  the  excitability  and  hyper-sensitivity  return  within  a 
few  months  and  later  epileptic  fits  occur. 

Treatment. — Prophylactic  treatment  has  already  been  re- 
ferred to  in  the  last  paragraph.  If  epilepsy  has  developed, 
it  is  important  to  try  to  discover  any  cause  if  possible,  and 
an  X-ray  photograph  should  be  taken  of  the  cranium.  If 
no  focal  lesion,  or  other  definite  cause,  can  be  found  the  treat- 
ment must  be  conducted  on  general  lines.  The  whole  of 
the  patient's  mode  of  hAdng  must  be  carefully  regulated 
and  instructions  must  be  given  as  to  clothing,  exercise,  and 
dietary.  The  clothing  must  be  as  hght  and  loose  as  possible. 
Eegular  exercise  must  be  taken,  but  fatigue  avoided.  Ex- 
haustion will  always  tend  to  bring  about  a  seizure.  Food 
must  be  hght  and  nourishing ;  meat  should  not  be  taken 
more  than  once  a  day.  Alcohol  is  contra-indicated  and  must 
not  be  allowed.  The  bowels  must  act  daily,  and  if  by  the 
evening  there  has  been  no  relief,  a  glycerine  suppository  or  a 
soap-and-water  injection  should  be  administered.  Attention 
to  the  bowels  must  never  on  any  account  be  neglected,  and 
the  physician  cannot  too  forcibly  impress  this  instruction  on 
the  patient. 

The  writer  strongly  recommends  that  sulphate  of  magne- 
sium be  given  in  conjunction  with  bromide  of  potassium,  as  he 
has  found  it  to  be  a  most  valuable  drug  in  the  treatment  of 
epilepsy.  The  dose  of  bromide  of  potassium  varies  according 
to  the  age  of  the  patient,  but  for  an  adult  the  following  pre- 
scription may  be  tried  :  pot.  brom.  gr.  xv,  mag.  sulph.  gr.  x, 
aqua  ad  §  j,  t.d.s.  The  bromide  can  be  reduced  or  increased 
according  to  requirements.  Smaller  doses  of  bromide  may 
frequently  be  given  with  advantage.  In  some  cases  calcium 
bromide  is   useful.     At   times,    especially   in    cases   of   minor 


HYSTERIA  AND  INSANITY  277 

epilepsy,  two  larger  closes  of  pot.  brom.  given  twice  a  day  will 
succeed  when  the  three  smaller  doses  fail.  Full  instructions 
must  be  given  on  all  matters  relating  to  the  patient's  safety. 

The  treatment  must  be  kept  up  for  two  and  a  half  to  three 
years  after  the  last  fit,  and  it  is  wise  for  the  patient  to  continue 
taking  five  or  ten  grains  of  potassium  bromide  once  a  day 
for  the  rest  of  his  hfe.  If  the  treatment  of  epilepsy  is  begun 
early  and  strictly  carried  out,  the  prognosis  is  by  no  means 
bad,  for  a  fairly  large  number  of  these  patients  recover.  In 
those  cases  in  which  the  bromides  are  found  to  fail,  tincture 
of  digitalis,  tincture  of  belladonna,  or  chloral  hydrate  should 
be  respectively  tried.  Hypnotic  suggestion  is  said  to  be  useful 
in  some  cases. 

If  insanity  is  associated  with  epilepsy,  it  is  frequently  neces- 
sary to  place  the  patient  under  care.  For  the  pre-paroxysmal 
attacks,  chloral  hydrate  should  be  added  to  the  bromide  of 
potassium  as  soon  as  the  mental  symptoms  show  themselves, 
and  it  is  wise  to  keep  the  patient  in  bed.  Chloral  hydrate  is 
also  useful  in  cases  of  status  epilepticus  and  should  be  admin- 
istered per  rectum. 

The  treatment  of  epileptic  insanity  to  a  certain  extent 
depends  on  the  type  of  the  mental  disorder.  Sudden  violent 
impulses  must  be  guarded  against,  and  the  patient  must  be 
under  constant  supervision  by  night  and  day. 

Hysteria  and  Insanity 

Hysteria,  so  far  as  the  public  mind  is  concerned,  has  practi- 
cally become  a  popular  term  which  includes  all  divers  disorders, 
physical  or  mental,  which  are  too  obscure  to  be  otherwise 
explained.  Many  persons  use  the  word  '  hysteria  '  to  denote 
various  forms,  often  serious  forms,  of  mental  disorder.  This 
is  largely  due  to  the  continued  use,  by  some  members  of 
the  medical  profession,  and  more  generally  by  the  public, 
of  the  obsolete  terms  '  mad  '  and  '  lunatic,'  and  also  to  the 
dread  with  which  mental  disorder  is  regarded  by  the  layman 
to  whom  by  tradition  it  is  a  condition  rather  of  shame  than  of 
disease.  In  the  present  state  of  pubhc  education  it  is  not 
a  matter  of  wonder  that  recourse  is  had  to  vague  language  to 
avoid  the  stigma  involved  in  the  admission  that  a  relative  is 


278  PSYCHOLOGICAL  MEDICINE 

insane.  So  the  patient  is  called  hj^sterical.  From  a  scientific 
standpoint  this  increasing  tendency  to  the  indiscriminate 
denomination  of  various  classes  of  insanity  mider  the  term 
'  hysteria  '  is  to  be  deplored.  Eegret  may  also  be  felt  that 
such  an  innocent  subterfuge  should,  as  it  undoubtedly  does, 
militate  against  the  more  speedy  education  of  the  public 
mind  to  a  recognition  that  mental  disorder  is  in  every  way 
comparable  to  physical  disease.  Hysteria  is  a  disorder  with 
very  definite  symptoms,  and  unless  these  symptoms  are  pre- 
sent, the  term  is  inapplicable.  It  has  a  bodily  and  a  mental 
aspect ;  when  the  latter  is  very  pronounced,  the  form&r  is 
apt  to  be  overlooked,  and  vice  versa.  During  recent  years 
Babinski  has  strongly  m'ged  and  has  frequently  demonstrated 
his  belief  that  hysteria  is  largely  produced  by  suggestion. 
He  states  that  hysteria  is  a  special  psychical  state  which  is 
capable  of  giving  rise  to  certain  conditions  wMch  have  features 
of  their  own.  It  manifests  itself  in  primary  and  secondary 
symptoms.  The  former  can  be  reproduced  exactly  by  sug- 
gestion in  certain  subjects  and  can  be  made  to  disappear 
under  the  sole  influence  of  persuasion  :  and  further,  that  which 
characterises  the  secondary  troubles  is  that  they  are  strictly 
subordinated  to  the  primary  troubles.  In  fact  Babinski  would 
appear  to  exclude  from  hysteria  any  sj'^mptoms  which  cannot  be 
produced  by  suggestion.  He  regards  the  patient  as  capable  of 
auto-suggestion.  When  actual  insanity  supervenes,  it  is  better 
to  look  upon  it  as  a  complication  of  hysteria  rather  than  a  special 
form  of  disorder,  though  clearly  the  mental  disorder  will  be 
coloured  bv  the  phenomena  pecuHar  to  hysteria. 

etiology. — Hysteria  may  occur  at  any  age,  but  it  is  more 
common  in  early  adult  life  and  is  twelve  to  sixteen  times  more 
common  in  females  than  in  males.  A  history  of  a  neurotic 
inheritance  is  frequently  obtainable.  An  hysterical  mother  may 
bear  offspring  who  in  later  hfe  also  become  hysterical,  and  in- 
sanity or  epilepsy  in  the  parents  may  lead  to  hysteria  in  their 
children.  In  brief,  the  same  disorders  which  may  predispose 
to  insanity  may  predispose  to  hysteria.  In  the  individual 
the  stress  which  produces  the  disorder  may  be  either  mental, 
moral,  or  physical ;  it  needs  no  argument  to  show  that  the 
stress  required  to  produce  the  condition  is  in  inverse  propor- 
tion to  the  stabihty  of  the  nervous  system. 


HYSTERIA  AND  INSANITY  279 

Hysteria  is  much  more  common  in  early  life,  and  it  is  often 
due  to  ill-directed  education.  I'or  true  stability,  it  is  necessary 
that  growth  should  be  slow  and  steady  and  that  the  mental 
development  should  not  be  forced  along  without  regard  to  the 
physical.  Bad  habits  should  be  corrected  at  once.  A  child 
should  be  treated  as  a  child  ;  regular  hours  of  rest  should  be 
insisted  upon  ;  the  modern  tendency  to  permit  young  girls  to 
stay  up  late  at  night,  attending  dances  and  theatres,  is  a  grievous 
error  ;  all  too  frequently  it  sows  the  seeds  of  future  years  of  ill 
health  and  disappointment.  Never  let  it  be  forgotten  that  rapid 
development  usually  implies  early  decay  ;  the  tendency  should 
rather  be  to  retard  than  to  hasten  evolution.  A  purposeless 
life  conduces  to  hysteria  ;  it  is  w^ell  that  all  young  women 
should  have  some  interest,  even  if  it  may  never  be  necessary 
for  them  to  earn  their  own  livelihood.  There  is  no  direct 
connection  between  hysteria  and  any  disease, of  the  sexual 
organs.  Hysteria  occurs  for  the  first  time  in  both  the  smgle 
and  married  and  marriage  is  certainly  about  the  worst  remedy 
that  can  be  prescribed  for  a  young  hysteric. 

The  various  stresses  which  may  act  as  predisposing  or 
exciting  causes  in  determining  an  attack  of  hysteria  need  not 
here  be  detailed  ;  they  v/ill  be  found  in  the  chapter  on  General 
Causation. 

Mental  Symptoms. — Hysterical  individuals  are  usually  social 
units  ;  persons  who  keep  a  good  deal  to  themselves,  though 
constantly  craving  for  the  sympathy  of  others.  In  hysteria, 
as  in  many  other  forms  of  mental  and  physical  disease,  '  sub- 
ject-consciousness '  is  increased,  accompanied  by  a  corre- 
sponding fall  in  '  object-consciousness.'  The  patient  becomes 
introspective  and  self-concentrated  and  jealous  of  personal 
comforts.  She  is  intensely  exacting  and  fault-finding  and  a 
constant  source  of  irritation  wherever  she  may  reside.  x\tten- 
tion  is  affected  ;  there  is  hyper-attention  regarding  self  and 
inattention  to  surroundings.  In  an  earlier  chapter  it  has  been 
explained  that  attention  is  absolutely  necessary  to  action,  and 
any  disorder  which  leads  to  inattention  may  make  the  patient 
appear  to  be  apathetic  and  indolent.  The  hysterical  woman  is 
self-centred  and  inattentive  to  her  surroundings  and  probably 
this  in  no  small  measure  accounts  for  her  inactivity.  The 
memory  is  affected  in  some  cases,  but  by  no  means  in  all. 


280  PSYCHOLOGICAL  MEDICINE 

There  is  a  tendency  to  exaggerate  ;  it  is  not  exactly  a  param- 
nesic  condition,  such  as  is  seen  in  the  romancing  of  patients 
with  Korsakow's  disease,  but  rehance  cannot  be  placed  upon 
the  statements  of  the  patient.  The  falsehood  is  not  always 
wilful ;  perhaps  an  incident  is  only  partially  remembered, 
and  the  account  of  it  may  thus  be  distorted.  Total  amnesia 
may  occur  after  a  fit,  and  there  may  be  a  period  of  time  con- 
cerning which  the  patient  remembers  nothing. 

The  hysterical  woman  is  very  emotional  and  has  violent 
outbm'sts  of  excitement  on  slight  provocation.  Her  mental 
instability  is  exhibited  by  these  attacks  of  laughing  or  weeping, 
and  at  times  she  is  quite  unable  to  control  her  emotions. 
These  hysterical  displays  rarely,  if  ever,  occur  when  the  patient 
is  alone,  but  they  are  by  no  means  uncommon  in  the  society 
of  others.  For  this  reason  many  persons  beheve  that  these 
outbm'sts  are  under  the  control  of  the  patient.  This  in  no 
way  follows  and  is  not  as  a  rule  the  case. 

The  vagaries  of  conduct  vary  in  degree  according  to  the 
severity  of  the  attack.  In  other  words,  the  conduct  is  in  keeping 
with  the  general  feelings  of  the  patient.  The  individual  may 
merely  be  apathetic  and  indolent,  or  may  be  markedly  erratic. 
There  is  lack  of  purpose  ;  at  one  time  excessive  activity,  at 
another-  idleness.  The  patient  is  very  impulsive  and  acts  upon 
the  fancy  of  the  moment.  Judgment  is  weak  and  unreliable. 
Suicide  is  often  tlireatened,  but  rarely  attempted.  On  the 
other  hand,  hysterical  individuals  not  uncommonly  inflict 
injuries  upon  themselves,  probably  from  a  desire  to  obtain  the 
sympathy  of  others. 

From  time  to  time  hysterical  patients  may  be  met  with 
who  seem  to  have  a  dual  existence  ;  or  it  may  be  that  the 
second  state  is  merely  sonmambulistic.  While  in  this  second 
state,  a  woman  may  do  all  kinds  of  extraordinary  things  ;  she 
may  steal,  set  fire  to  the  furniture  or  house,  or  wander  about 
half-clothed.  WTien  she  returns  to  her  normal  condition  she 
may  remember  little  or  nothing  of  what  she  has  done.  The 
memory  in  each  state  is  often  distinct  ;  when  she  returns  to 
the  second  state,  she  thinks  and  acts  as  she  did  when  previously 
in  that  state.  Occasionally  it  seems  that  the  second  personality 
knows  all  about  the  first,  but  the  latter  knows  nothing  about 
the  second. 


HYSTERIA  AND  INSANITY  281 

Insanity  of  the  delirious  or  maniacal  type  may  supervene. 
In  many  ways  the  condition  closely  resembles  that  of  ordinary 
acute  mania  with  the  characteristic  symptoms  of  hysteria 
superadded.  Visual  hallucinations  are  common.  From  time 
to  time  there  are  outbursts  of  violence  and  passion.  Movement 
is  quick  and  the  speech  is  incoherent.  Gesticulations  and 
dramatic  attitudes  are  not  infrequently  to  be  observed.  Pitres 
has  described  a  condition  which  he  calls  '  ecmnesia,'  where 
the  patient  has  a  com,plete  loss  of  memory  for  a  certain  number 
of  recent  years  and  his  actions  and  thoughts  correspond  to  this 
loss  of  memory. 

Physical  Symptoms. — The  physical  symptoms  of  hysteria  are 
so  numerous  that  only  a  brief  reference  to  them  is  possible  ; 
the  reader  must  turn  to  works  on  medicine  for  a  more  minute 
account.  The  digestive  organs  may  show  various  disturbances. 
Vomiting  may  be  an  urgent  sym.ptom  and  one  that  is  by  no 
means  easy  to  treat.  Anorexia  is  common,  and  there  may 
be  absolute  refusal  of  food.  Eecourse  should  be  had  to 
artificial  feeding  by  means  of  the  oesophageal  or  nasal  tube  ; 
otherwise  the  patient  will  die  from  inanition.  The  circulatory 
system  may  be  disordered  ;  the  patient  may  complain  of 
palpitation  and  flutterings  in  the  region  of  the  heart.  The 
respiration  calls  for  no  special  notice.  The  secretions  may  be 
affected  and  are  usually  excessive  in  amount.  The  urine  is 
greatly  increased  in  quantity.  Hysterical  '  anuria  '  has  been 
recorded,  but  it  is  a  very  rare  symptom. 

The  special  senses  and  sensations  in  general  are  usually  in 
some  way  altered  in  hysteria.  From  the  standpoint  of  insanity 
this  symptom  is  of  importance,  when  it  is  remembered  that  it 
is  largely  from  sensations,  and  ideas  of  past  sensations  that 
the  knowledge  of  '  self '  is  derived.  Altered  sensations  are 
a  common  cause  of  illusions,  and  these  disordered  sensations 
may  be  the  basis  of  many  of  the  erroneous  ideas  expressed  by 
hysterical  patients.  The  sensory  phenomena  may  be  of  all 
kinds.  Anaesthesia  may  occur  either  locally  or  in  widely 
scattered  areas  ;  it  may  be  confined  to  skin  surfaces  or  ex- 
tend more  deeply  and  lead  to  analgesia.  Hemi-anaesthesia, 
especially  of  the  left  side,  is  not  an  uncommon  symptom,  and 
it  usually  affects  sensation  for  touch,  pain,  heat  and  cold. 
Janet  has  pointed  out,  when  being  tested  with  the  eyes  bhnd- 


282  PSYCHOLOGICAL  MEDICINE 

folded  and  told  to  say  '  Yes  '  or '  No  '  when  touched,  the  patient 
may  say  '  No  '  when  touched  upon  the  anaesthetic  side,  clearly 
showing  that  she  does  feel ;  this  is  known  as  Janet's  sign. 
The  special  senses  are  usually  involved  in  cases  of  hemianses- 
thesia  ;  the  patient  may  be  able  only  to  smell  with  one  nostril, 
or  to  taste  on  one  side  of  the  tongue.  Hysterical  anaesthesia 
whenever  it  occurs  never  follows  the  distribution  of  a  nerve 
or  nerve-root.  The  field  of  vision  may  be  limited  in  area. 
Hypersesthesia  is  sometimes  found.  Neuralgia  and  headaches 
may  also  occur  ;  local  acute  pain  in  the  head  may  take  the 
form  of  the  well-known  '  clavus.'  Complaints  of  areas  of 
local  pain  are  sometimes  made,  more  especially  in  the  spinal 
regions  and  various  joints  ;  the  latter  may  become  quite  fixed 
in  consequence.  Ocular  and  visual  disturbances  are  very 
numerous,  and  special  reference  may  be  made  to  photophobia 
and,  as  occasionally  occurs,  complete  blindness  in  one  or  both 
eyes.  Loss  of  vision  for  colours  is  a  characteristic  symptom. 
If  the  vision  is  tested  by  a  perimeter,  the  visual  field  will  usually 
be  found  to  show  concentric  lessening. 

The  motor  phenomena,  like  the  sensory,  vary  in  severity. 
Adductor  paralysis  of  the  vocal  cords  may  lead  to  aphonia. 
Paresis  or  paralysis  may  occur  locally  or  may  affect  several 
limbs.  Commonly  the  whole  limb  is  paralysed,  or  there  may 
be  loss  of  power  in  both  extremities  with  total  inabiUty  to  walk. 
The  knee-jerks  are  never  absent  in  hysteria,  but  they  may  be 
exaggerated.  True  ankle  clonus  probably  never  occurs  in  this 
condition,  but  a  spurious  ankle  clonus  may  be  observed.  This 
latter  quickly  stops  ;  and  further,  the  first  contraction  is  an  ex- 
tension of  the  ankle,  whereas  in  true  ankle  clonus  the  movement 
is  at  first  a  dorsi-flexion.  The  plantar  reflexes  are  usually 
absent,  but  if  present  they  are  flexor  and  never  extensor. 

To  return  to  the  various  forms  of  paralysis  :  they  are  un- 
attended by  any  rapid  wasting  of  the  muscles,  and  there  is 
no  fibrillary  twitching  of  the  muscles.  Electrically  they  show 
no  reaction  of  degeneration.  Contracture  of  a  severe  kind 
may  occur  in  hysteria.  Flexion  of  the  wrist  and  fingers  is 
frequently  observed.  In  the  lower  extremities  the  limbs  may 
be  doubled  up.  Charcot  points  out  certain  distinguishing 
features  which  will  help  the  physician  to  diagnose  functional 
contractures  from   those  which  result  from  organic   disease. 


HYSTERIA  AND  INSANITY  283 

In  the  former  class  (a)  the  onset  is  more  rapid,  and  its  appear- 
ance may  be  determined  by  some  shght  injury  or  nervous 
shock  ;  (b)  the  contracture  is  often  very  extreme,  and  in 
the  case  of  the  fingers  the  nails  may  be  driven  into  the  palms  ; 
(c)  the  contracture  does  not  improve  or  disappear  during 
or  after  natural  sleep  ;  {d)  anaesthesia,  unless  pressed  very 
deeply,  does  not  cause  relaxation.  Todd  has  pointed  out 
a  difference  in  the  gait  of  an  hysterical  hemiplegia,  as  dis- 
tinguished from  that  of  the  sufferer  from  organic  disease. 
The  former  merely  drags  the  limb,  while  the  latter  swings 
it  round  in  order  to  clear  the  ground  ;  also  if  the  patient  is 
laid  down  fiat  with  body  and  limbs  extended,  the  arms  resting 
by  the  side  of  the  trunk,  and  he  is  then  told  to  sit  up  without 
using  the  hands  or  arms,  the  paralysed  leg  does  not  rise  so 
far  from  the  ground  as  the  non-paralysed  one  in  a  functional 
disorder  such  as  hysteria,  whereas  in  organic  disease  it  is 
thrown  up  much  higher. 

Among  hysterical  patients  tremors  and  spasms  are  some- 
times met  with.  Eetention  of  urine  is  a  common  symptom, 
but  if  left  the  bladder  usually  empties  itself,  though  in  severe 
cases  a  catheter  may  have  to  be  used.  Convulsive  seizures 
are  by  no  means  uncommon  and  are  frequently  preceded 
by  a  sense  of  suffocation.  They  vary  greatly  in  severity  and 
may  be  so  mild  as  to  consist  merely  of  outbursts  of  uncontrol- 
lable weeping  or  laughter,  accompanied  by  general  agitation 
and  restlessness.  Seizures  may  be  more  severe  and  be  pre- 
ceded by  an  '  aura  hysterica,'  which  usually  consists  of  some 
abdominal  pain  or  globus.  On  the  access  of  the  fit  the  patient 
falls,  but  not  so  helplessly  as  the  epileptic.  There  is  apparent 
loss  of  consciousness,  but  the  corneal  reflexes  are  present ;  the 
patient  may  resist  being  moved.  Again,  in  the  second  or 
clonic  stage,  the  condition  differs  from  epilepsy  in  that  the 
movements  are  frequently  purposive,  and  the  patient  may 
throw  herself  about  violently.  The  hysterical  seizure  usually 
lasts  a  long  time  until  exhaustion  supervenes.  Urine  is 
seldom,  if  ever,  unconsciously  passed.  There  is  a  still  more 
severe  form  of  seizure  known  as  the  '  hystero-epileptic  fit.' 
The  attack  when  fully  developed  consists  of  four  stages.  The 
first  is  the  ejpih'ptoid,  and  begins  with  definite  tonic  muscular 
spasms  ;    the  features   become  distorted,  and  there  may  be 


284  PSYCHOLOGICAL  MEDICINE 

interference  with  respiration.  Within  a  short  time  the  second 
phase  of  the  fit  develops  ;  in  this  the  patient  goes  through 
extraordinary  contortions  {the  'period  of  cJavinism)  and  may 
arch  the  body  so  that  the  head  and  heels  meet.  During 
this  stage  there  may  be  violent  screaming.  The  next  phase 
appears  before  long :  in  this  the  patient  seems  to  react 
to  her  thoughts,  and  takes  up  various  attitudes  {attitudes 
jMSsionnelles).  Probably  throughout  this  stage  she  is  mi- 
conscious  of  her  surroundings.  The  last  phase  is  one  of  mental 
excitement. 

The  physical  symptoms  vary  in  severity.  If  there  is  no 
refusal  of  food  the  patient  does  not  usually  lose  weight  very 
rapidly.  Sleep  is  not  always  bad.  The  catamenial  functions 
are  as  a  rule  disordered,  and  the  mental  symptoms  com- 
monly show  a  periodic  tendency,  being  much  worse  either 
immediately  before  or  after  menstruation. 

Diagnosis. — Hysteria  has  to  be  distinguished  from  organic 
disease,  which  may  be  complicated  by  hysterical  symptoms. 
Usually  the  incongruity  of  the  physical  signs  are  of  great 
assistance  in  forming  a  right  diagnosis.  For  example,  a  case 
of  total  paraplegia  may  occur  without  any  bladder  symptoms. 
The  chief  points  to  be  considered  are  :  the  sex,  age,  condition 
of  reflexes,  the  concentric  lessening  of  visual  fields,  and  the 
incongruity  of  the  sensory  and  motor  disturbances.  The 
hysterical  fit  can  usually  be  stopped  by  use  of  the  faradaic 
current,  or  by  pressure  on  the  inguinal  region.  Hysteria, 
when  well  developed,  is  very  easily  diagnosed  ;  it  is  in  the 
early  stages  that  the  difficulty  arises.  The  mental  state  is 
helpful  in  arriving  at  a  true  diagnosis  The  reader  should 
refer  to  a  text-book  on  medicine  or  nervous  diseases  for  a  full 
account  of  hysteria,  as  space  merely  suffices  here  for  a  brief 
description  of  the  disorder. 

Prognosis. — It  is  very  difiicult  to  forecast  a  case  of  hysteria. 
As  the  patient  is  a  neurotic  and  unstable  individual,  recovery 
may  be  rapid  even  when  the  condition  seems  serious.  On  the 
other  hand,  relapses  are  very  probable.  If  the  patient  can  be 
removed  from  home  and  placed  under  proper,  treatment,  the 
prognosis  is  usually  good.  To  treat  an  hysterical  woman  in 
her  o-\vn  home  is  usually  disappointing  both  to  the  physician 
and   friends.     Constant  refusal  of   food  is  a   bad   symptom, 


HYSTERIA  AND  INSANITY  285 

and  imless  firmly   dealt  with,   the  patient  not  uncommonly 
dies.     Vomiting,  also,  may  be  a  serious  symptom. 

Pathology. — The  pathology  of  this  condition  is  very  ob- 
scure. Some  authorities  have  tried  to  explain  hysteria  on 
physical  gromids,  others  from  the  psychological  standpoint. 
Moebius  looks  upon  hysteria  as  primarily  a  congenital  morbid 
mental  state  and  holds  that  the  physical  symptoms  are 
secondary,  produced  merely  by  the  disordered  ideas.  Janet 
has  defined  hysteria  as  '  a  psychosis  belonging  to  the  group 
of  maladies  due  to  cerebral  insufficiency  ;  it  is  above  all 
characterised  by  moral  symptoms  of  which  the  principal 
is  an  enfeeblement  of  the  faculty  of  psychological  syn- 
thesis.' Elsewhere  he  describes  it  as  'a  form  of  mental 
depression  characterised  by  the  retraction  of  the  field  of 
personal  consciousness  and  a  tendency  to  the  dissociation 
and  emancipation  of  the  systems  of  ideas  and  fmictions 
that  constitute  personality.'  We  have  alread}^  referred  to 
the  view  held  by  Babinski. 

Treatment. — The  treatment  of  hysteria  is  both  prophy- 
lactic and  curative.  With  regard  to  the  former,  much  can  be 
done  by  parents  and  teachers  in  the  early  education  and 
teaching  of  the  young.  If  a  child  is  Imown  to  be  unstable, 
or  if  the  family  history  of  a  child  is  unsound,  special  care 
must  be  taken  that  the  education  is  upon  broad  lines.  As 
much  attention  must  be  bestowed  on  the  development  of  the 
body  as  on  the  mental  training. 

Formerly  the  necessity  of  attending  to  the  physical  develop- 
ment during  early  adult  life  was  too  frequently  forgotten  ; 
girls  were  remarked  rather  for  their  frailness  than  their  good 
physique.  The  tendency  of  the  present  age  is  to  remedy  this 
•evil,  though  care  must  be  taken  not  to  allow  the  pendulum 
to  swing  too  far  in  the  opposite  direction. 

To  pass  on  to  curative  treatment  :  when  the  case  is  known 
to  be  one  of  hysteria,  there  are  certain  general  rules  to  be 
followed.  Never  fail  to  treat  the  patient  as  one  suffering 
from  some  illness.  Never  allow  a  suggestion  of  malingering 
to  be  breathed  ;  in  the  fii'st  place,  it  is,  as  a  rule,  unfounded  ; 
in  the  second,  whether  it  be  well-  or  ill-founded,  the  knowledge 
that  you  have  ventured  such  a  suggestion  will  infallibly  forfeit 
your   hold    upon  the  patient.     Too  much  sympathy  is  bad, 


286  PSYCHOLOGICAL  MEDICINE 

and  this  is  where  home  treatment  so  often  fails.  A  patient 
should  be  treated  firmly  but  kindly.  Constant  encom-age- 
ment  is  required  :  though  it  may  be  quite  impossible  for 
patients  to  throw  off  apathy  and  rouse  themselves,  as  they 
are  usually  told  to  do,  encouragement  may  induce  them  in 
their  better  hours  to  employ  themselves  and  thus  turn  their 
attention  to  things  outside  themselves. 

Hysterical  patients  are  often  most  irritating  and  annoying, 
and  it  is  difficult  not  to  believe  that  there  is  method  in  their 
conversation  and  conduct.  Apart  from  its  being  uncharitable, 
it  is  unjust  to  consider  or  treat  them  as  normal  beings.  Their 
mental  aberration  is  part  of  their  complaint,  and  by  this 
they  should  be  judged.  If  possible  the  patient  should  be 
placed  with  strangers.  Her  life  should  be  so  regulated  as  to 
provide  for  early  retirement  to  bed  ;  diet  should  be  liberal 
and  of  a  nourishing  nature  and  plenty  of  milk  should  be  taken. 
Exercise  should  not  be  excessive  at  first,  and  travelling  is 
decidedly  bad.  Games  such  as  golf  and  hockey  are  useful 
in  assisting  recovery  when  the  patient's  general  physical 
condition  renders  it  possible.  If  there  is  great  bodily  weak- 
ness total  rest  in  bed  is  necessary,  and  at  times  complete 
isolation  from  friends  is  advisable.  Weir-Mitchell  treatment, 
or  some  modified  form  of  it,  is  useful  in  some  cases.  The 
physician  should  always  impress  upon  the  patient  that  he 
thoroughly  understands  the  illness,  for  it  must  not  be  for- 
gotten that  the  hysterical  person  is  very  '  suggestible  '  and 
will  quickly  decide  whether  confidence  may  be  reposed  in  the 
medical  attendant. 

If  possible  the  treatment  should  be  kept  on  broad  lines. 
Baths  of  all  kinds  are  frequently  very  beneficial,  and  in  some 
cases  electrical  treatment  may  be  employed  with  advantage. 
Local  treatment  or  the  treatment  of  vague  symptoms  is  unwise, 
as  it  is  apt  to  direct  attention  and  provoke  concentration 
on  the  ailment  in  question.  The  value  of  hypnosis  is  still 
doubtful,  but  it  may  be  very  successful  in  some  cases.  If 
suggestion  causes  the  iUness  it  seems  logical  that  suggestion 
might  remove  it.  The  danger  is  that  it  is  apt  to  augment  the 
already  hyper-suggestible  state  of  the  patient,  and  it  is  on  this 
ground  that  some  authorities  condemn  it.  Drug  treatment  is 
valuable  chiefly  from  its  moral  effect,  and  greatly  assists  the 


TRAUMATIC  NEUROSES  287 

general  routine.  Whatever  is  done  must  be  done  actively, 
for  the  patient  must  never  be  allowed  to  lose  confidence  either 
in  her  physician  or  nurses.  Marriage  should  never  be  recom- 
mended ;  it  usually  aggravates  rather  than  alleviates  the 
condition.  If  the  mental  symptoms  become  serious  it  may 
be  necessary  to  resort  to  asylum  treatment.  Eefusal  of  food 
should  at  once  be  dealt  with,  especially  if  the  patient  is  losing 
weight.  Forced  feeding  by  means  of  the  nasal  or  oesophageal 
tube  should  not  be  delayed  if  necessary  ;  a  single  feeding  by 
such  means  may  have  a  useful  moral  effect. 


Traumatic  Neuroses 

The  whole  subject  of  traumatic  neuroses  is  one  which  has 
exercised  the  minds  of  both  the  medical  and  the  legal  profes- 
sions for  many  years.  It  is  a  matter  of  no  small  concern  to 
insm'ance  companies  and  large  employers  of  labour.  Great 
surgeons  have  discussed  the  question  and  expressed  diverse 
opinions,  but  the  subject  is  perhaps  more  properly  within  the 
province  of  the  physician  who  has  made  mental  and  nervous 
disorders  his  special  study.  So  many  traumatic  nem^oses  are 
obscure  nervous  complaints  and  in  many  instances  are  purely 
mental  in  character.  Unless  the  investigator  is  thoroughly 
conversant  with  the  various  disorders  of  the  mind,  he  is  apt 
unwittingly  to  misinterpret  real  symptoms  into  foolish  fancies 
and  misconstrue  definite  signs  of  disorder  into  pure  imagina- 
tion. Again,  if  it  is  true  that  post-traumatic  states  are  the 
happy  hunting-ground  of  the  impostor  and  adept  malingerer, 
surely  he  can  only  be  met  by  the  physician  who  knows  true 
mental  disorder  when  he  sees  it. 

Some  traumatic  neuroses  are  due  to  gross  lesions  and 
come  within  the  province  of  the  surgeon  ;  but  where  the  con- 
dition is  rather  one  of  functional  disorder  of  the  mind,  the 
opinion  of  the  mental  physician  must  necessarily  carry  greater 
weight.  Oppenhcim,  in  1889,  showed  that  there  were  in 
reality  two  classes  of  cases  following  traumatism,  viz.  those 
with  organic  injuries,  and  those  which  were  not  marked  with 
any  gross  lesion.  To  the  latter,  to  which  he  applied  the  term 
traumatic    neuroses,    this    chapter    specially    applies.     Many 


288  PSYCHOLOGICAL  MEDICINE 

writers  prefer  to  treat  all  cases  of  functional  nervous  disorder 
of  a  traumatic  origin  under  the  head  of  hysteria  or  neur- 
asthenia. The  condition  is  in  fact  one  of  chronic  nerve  ex- 
haustion occasioned  by  the  injury,  and  the  symptoms  closely 
resemble  those  found  in  j)atients  suffering  from  the  ordinary 
chronic  nerve  exhaustion  of  the  non-traumatic  type. 

.ffitiology. — The  apparent  injury  to  the  head  may  be  very 
slight,  and  in  some  cases  none  can  be  discovered.  The  base 
of  the  brain  may  be  concussed  by  the  patient  falling  heavily 
on  his  feet  or  gluteal  region,  or  by  some  other  severe  physical 
shock,  ki  many  cases  there  is  a  history  of  a  very  definite 
head-injury  followed  by  a  period  of  mental  confusion  or  abso- 
lute unconsciousness.  Westphal  believes  that  there  is  always 
some  organic  basis  to  be  discovered,  but  most  authorities  dis- 
agree with  this  view  and  consider  that  any  subsequent  neurosis 
must  be  purely  psychical  in  origin.  The  effect  of  the  mental 
shock  must  not  be  lost  sight  of ;  it  may  occur  at  once,  or  may 
not  apparently  develop  for  some  time.  In  the  latter  class 
of  ease  there  is  usually  some  mental  change,  but  so  slight 
that  it  is  either  overlooked,  or  if  observed  does  not  receive 
the  recognition  which  its  importance  warrants.  In  this  lies 
a  great  pitfall  for  the  unwary.  It  must  be  admitted  to  be 
within  the  bounds  of  possibility,  or  even  probability,  that 
a  severe  fright  or  other  great  emotional  disturbance,  however 
brief  its  duration,  may  have  such  an  effect  upon  the  nervous 
mechanism  that  its  functions  are  not  afterwards  carried  out 
as  they  were  before  the  shock.  For  a  time  the  errors  of  action 
may  be  compensated  for  in  other  ways  and  therefore  little  or 
no  change  be  noticed. 

In  cases  where  there  has  been  severe  shock  or  concussion 
of  the  brain,  the  acute  symptoms  may  pass  off  after  a  few 
days,  and  the  patient  may  appear  to  be  well,  and  remain 
so  for  some  weeks  or  months.  Later  other  nervous  and 
mental  symptoms  may  develop.  The  question  that  is  always 
asked  is,  How  do  you  account  for  this  period  of  health  if  the 
later  symptoms  are  produced  by  the  accident  ?  Clearly  the 
answer  must  be,  that  this  apparent  recovery  is  only  from 
the  urgent  and  acute  symptoms,  whereas  the  sequelae  are  of 
slow  development.  Further,  the  restoration  above  referred  to 
is  rarely  a  complete  recovery,  and  usually  several  abnormal 
mental  symptoms  are  to  be  observed. 


TRAUMATIC  NEUROSES  289 

In  some  cases  the  accident  is  followed  by  a  period  of  in- 
somnia, which  in  time  gives  rise  to  mental  disturbances  of 
varying  degrees.  Alcoholics  and  syphilitics  are  more  liable 
than  others  to  suffer  bad  effects  from  injuries  to  the  head 
resulting  from  blows  or  falls.  Some  persons  who  have  had 
a  head-injury  are  afterwards  unable  to  take  any  stimulant 
without  exhibiting  some  temporary  mental  aberration  and 
this  disturbance  may  become  of  a  more  permanent  nature. 
A  cranial  injury  may  be  followed  within  a  short  time  by 
symptoms  of  general  paralysis,  but  in  this  event  the  accident 
is  only  the  determining  and  not  the  primary  cause  of  the 
disease. 

To  sum  up  :  it  is  impossible  to  foresee  what  the  effects  of  a 
head-injury,  whether  slight  or  severe,  will  be,  for  there  are  so 
many  factors  which  may  contribute  to  the  sum-total  of  the 
effects  of  an  accident.  There  is  the  mental  constitution,  which 
may  be  of  such  an  unstable  nature  that  a  severe  fright  or  cerebral 
concussion  may  give  rise  to  an  acute  or  chronic  form  of  mental 
disorder.  There  are,  too,  many  acquired  conditions,  in  which 
must  be  included  the  effects  of  previous  mental  or  physical 
illness,  intemperance,  and  indirect  stress,  such  as  domestic 
loss  and  worry  from  straitened  circumstances.  All  or  any 
of  these  may  contribute  to  produce  mental  disorder  in  one 
who  has  had  concussion  or  injury  to  the  head. 

Mental  Symptoms. — Intellectual  disorders  may  at  once 
succeed  the  accident,  or  they  may  slowly  develop  as  the  imme- 
diate symptoms  pass  off.  In  many  cases  it  is  only  after 
several  weeks  or  months  that  the  mental  change  is  to  be  re- 
cognised. The  patient  becomes  very  irritable  and  querulous. 
He  may  formerly  have  been  placid  and  good-tempered,  but 
now  he  is  always  complaining  and  fault-finding.  Slight  sounds 
irritate  him  and  '  get  on  his  nerves.'  He  is  readily  fatigued 
and  the  memory  is  uncertain  or  may  be  distinctly  bad.  He 
is  easily  distracted  and  a  prolonged  effort  of  attention  is  im- 
possible. In  some  cases  the  mind  is  in  a  constant  state  of 
confusion  with  total  inability  to  grasp  the  purport  of  any 
communication.  The  once  successful  business  man  becomes 
an  absolute  failure.  Despondency  and  even  actual  depression 
are  common  symptoms.  Attempts  at  self-destruction  may 
be  provoked  by  the  feeling  of  inability  to  work,  and  the  idea 
that  a  continuance  of  life  means  only  a  burden  to  all  concerned, 

19 


290  PSYCHOLOGICAL  MEDICINE 

Vague  fears  may  hamit  the  patient.  After  an  accident  some 
men  become  the  victims  of  all  kinds  of  obsessions  from  which 
they  cannot  escape.  Deiinite  exhaustion  and  confusional 
states  may  develop  and  some  patients  express  delusions  of 
various  kinds,  and  these  may  take  the  form  of  suspicions 
against  their  relatives.  In  very  severe  cages  the  condition 
may  be  one  of  progressive  dementia. 

Physical  Symptoms. — The  physical  disturbances  are  largely 
subjective.  Headache  is  very  common  and  may  be  almost 
continual  or  confined  to  times  when  w^ork  or  concentrated 
thought  is  attempted.  The  patient  often  complains  that  he 
is  una?jle  to  read,  as  the  letters  all  ran  together.  Einging 
noises  in  tlie  ears  may  cause  much  annoyance.  Sensation  may 
be  affected.  Some  of  these  patients  suffer  from  pain  in  the 
back  of  the  neck  or  in  the  lumbo-dorsal  region.  Fine  tremors 
can  usually  be  observed  in  the  tongue,  face,  or  fingers. 
Bladder  troubles,  for  which  no  definite  caase  can  be  dis- 
covered, are  by  no  means  rare.  The  general  health  usually 
suffers,  and  the  body  Aveight  falls.  The  appetite  is  bad,  and 
chronic  dyspepsia  may  develop.  Sleep  may  be  very  disturbed 
and  is  deficient  in  quality  as  well  as  quantity. 

Course. — The  course  is  usually  a  long  one.  Months  ma,y  pass, 
and  yet  there  is  little  or  no  improvement.  In  the  favourable 
cases  the  powers  of  attention  and  thought  begin  to  return, 
and  the  contmual  sense  of  fatigue  disappears.  The  memory 
becomes  more  accurate.  The  body  weight  increases  and  all 
other  physical  disturbances  pass  aw^ay. 

Prognosis. — There  is  probably  no  disorder  which  tests  the 
prognostic  powers  of  the  physician  so  severely  as  this  complaint. 
It  has  already  been  pointed  out  that  there  are  many  factors  to 
be  considered  before  a  decision  can  be  made.  The  severity 
of  the  accident  is  undoubtedly  of  importance,  but  the  past 
and  present  history  of  the  person  who  has  been  injured  must 
be  duly  weighed. 

There  are  tw-o  judgments  to  be  made  :  (a)  What  is  the 
immediate  prospect  ?  {b)  What  is  the  ultimate  prognosis  ? 
Recovery  may  in  some  cases  take  place  after  several  months 
or  years  ;  others  may  remain  mentally  crippled  for  Hfe,  and 
yet  be  capable  of  enjoying  life  so  long  as  they  have  not  to 
earn  their  living.     These  are  the  cases  which  the  lay  mind 


TRAUMATIC  NEUROSES  291 

fails  to  understand.  The  fact  that  a  man  looks  strong  or 
healthy  and  can  play  golf  or  other  games  connotes,  to  the 
mmd  untrained  in  mental  disorders,  that  he  is  equally  capable 
of  work  if  he  would  only  direct  his  attention  to  it.  But  this 
is  the  difficulty ;  he  cannot  concentrate  his  attention  for 
more  than  a  few  moments  together.  The  working  of  the 
brain  is  very  subtle.  It  does  not  require  a  great  shock  to 
disorganise  it,  if  the  shock  is  applied  in  the  direction  which 
will  cause  the  greatest  damage.  This  is  a  point  which  is  apt 
to  be  overlooked.  Almost  everything,  animate  or  inanimate, 
is  more  vulnerable  if  struck  in  a  particular  direction  ;  if  the 
blow  should  chance  to  come  in  that  direction,  the  force  re- 
quired to  do  damage  may  be  very  slight.  Again,  it  does 
not  follow  that,  because  a  blow  has  not  been  severe  enough  to 
injure  the  stronger  structures,  the  finer  mechanisms  have  not 
suffered  damage.  It  is  quite  conceivable  that  an  injury  to 
the  brain  may  be  such  that  only  the  highest  f mictions  are 
affected  and  that  those  more  organised  are  to  a  greater  or 
less  extent  left  intact.  In  brief,  the  power  of  concentrated 
attention,  the  attributes  which  go  to  made  a  sound  memory 
for  recent  events,  and  those  for  control,  and  the  hke,  may  all 
suffer,  and  yet  the  grosser  functions,  which  have  a  greater 
hold  on  the  organism,  may  remain  undamaged. 

Diagnosis. — The  value  of  making  an  accurate  diagnosis 
hes  less  in  distinguishing  between  this  complaint  and  neur- 
asthenia or  some  other  disorder  than  in  ability  to  detect  the 
malingerer.  Insurance  companies  and  employers  of  labour 
are  particularly  Uable  to  fraudulent  claims  by  persons  who 
hope  to  get  substantial  damages  for  injuries  received.  By  aU 
means  let  care  be  taken  to  frustrate  the  plans  of  the  pretender, 
but  in  doing  so  it  is  important  not  to  do  wrong  to  an  honest 
man.  The  malingerer  can  usually  be  detected  by  the  incon- 
gruity of  the  symptoms  of  which  he  complains.  It  is  the 
whole  pictm'e  which  indicates  whether  a  case  is  true  or  false, 
and  not  one  or  two  isolated  details.  The  patient  may  lay 
stress  on  certain  points  which  especially  attract  his  attention, 
but  inquuy  may  establish  other  changes,  mental  or  physical. 
See  the  patient  and  the  friends  separately  and  note  whether 
then  stories  agree.  In  examining  the  various  persons  inquire 
for  the  presence  of  unhkely  symptoms  :  the  malingerer  may  by 


292  PSYCHOLOGICAL  MEDICINE 

his  answers  declare  himself.  Never  show  any  surprise  at  an 
answer  given.  Let  the  patient  tell  his  own  story  first  and 
avoid  leading- questions. 

Treatment. — The  treatment  must  be  on  general  lines. 
Complete  rest  in  bed  for  a  month  or  six  weeks  is  frequently 
very  beneficial.  In  any  case,  there  must  be  absolute  cessation 
of  all  work,  and  all  business  matters  should  as  far  as  possible 
be  avoided.  If  any  litigation  is  pending,  the  patient  must 
leave  all  arrangements  to  his  solicitor  and  friends.  Massage 
and  gentle  exercise  are  beneficial  in  some  cases  ;  others  are 
more  benefited  by  a  course  of  baths.  Diet  should  be  liberal 
and  of  a  nourishing  nature.  Meals  should  be  frequent  and 
not  too  large  in  amount.  Food  must  be  taken  at  night.  In 
severe  cases  it  is  advisable  to  have  the  patient  treated  in  some 
nursing  home  or  institution  entirely  removed  from  his  friends. 
When  the  physical  health  is  fully  re-established,  some  light 
employment  may  be  attempted,  but  fatigue  must  be  avoided. 
The  patient  must  be  encouraged  to  look  for  complete  restora- 
tion to  health.  Let  it  always  be  borne  in  mind  that  recovery 
cannot  be  hastened  ;  too  early  attempts  at  work  only  lead  to 
disappointment  and  an  aggravation  of  the  symptoms. 


29S 


CHAPTEE  XVII 

PSYCHASTHENIA  AND  OBSESSIONS 

Several  names  have  been  used  to  denote  the  disorder  about 
to  be  described,  those  most  commonly  used  being  '  obsessions  ' 
and  '  compulsive  ideas.'  Hack  Tuke  defines  the  condition  as 
follows  :  '  Imperative  ideas  are  morbid  suggestions  and  ideas 
imperiously  demanding  notice,  the  patient  being  painfully 
conscious  of  their  domination  over  his  wish  and  will.'  Legrain 
asserts  '  that  impulse  bears  the  same  relation  to  acts  that 
obsession  does  to  ideas,'  and  further  states  '  that  every  cerebral 
manifestation,  either  of  the  intellect  or  of  the  affections,  which, 
in  spite  of  the  efforts  of  the  will,  forces  itself  upon  the  mind, 
thus  interrupting  for  a  time  or  in  an  intermittent  manner  the 
regular  course  of  association  of  ideas,  is  an  obsession.'  The 
same  writer  states  '  that  two  elements  are  indispensable  to 
obsession  :  (1)  a  centre  which  suddenly  and  isolatedly  enters 
into  functions,  its  action  not  being  required  by  the  mental 
needs  of  the  moment  ;  (2)  temporary  impotence  of  the  will 
to 'remove  this  obsession.' 

The  intellectual  powers  are  usually  good.  Almost  everybody 
at  some  period  of  life  has  probably  suffered  from  imperative 
ideas  in  a  mild  form.  Obsessions  indeed  afford  an  excellent 
example  of  the  fineness  of  the  line  which  separates  sanity  from 
insanity.  Take,  for  instance,  a  man  who,  as  soon  as  he  has 
turned  the  gas  off  at  night,  wonders  whether  the  tap  is  properly 
shut  off  and  returns  to  inspect  it,  and  no  sooner  has  he  again 
left  than  doubts  creep  into  his  mind  and  once  more  he  feels 
compelled  to  examine  the  tap.  The  normal  man  may  return 
once  or  even  twice,  but  if  the  night  is  spent  in  repeated  in- 
spections, the  condition  becomes  so  pathological  that  it  is 
necessary  for  the  person  to  be  placed  under  care. 

Imperative  ideas  cannot  be  looked  upon  as  necessarily  indi- 
cative of  insanity.     This  question  must  be  decided  upon  other 


294  PSYCHOLOGICAL  IVIEDICINE 

considerations,  e.g.  whether  the  patient  is  able  to  look  after 
himself  and  earn  his  own  living,  whether  he  is  able  to  direct 
his  thoughts  to  other  things,  or  whether  the  obsession  leads 
to  serious  depression  or  suicidal  feelings.  Many  persons  with 
obsessions  are  able  to  follow  their  usual  occupations  notwith- 
standing the  intermittent  return  of  the  troublesome  ideas. 

etiology. — A  neuropathic  inheritance  is  to  be  found  in  the 
majority  of  persons  who  suffer  to  any  serious  extent  from 
imperative  ideas.  They  may  occur  in  the  stable  man,  but  he 
is  able  to  put  them  aside  and  ignore  them.  Ill-health  tends 
to  strengthen  them  and  to  render  them  more  formidable  ; 
the  power  of  resistance  is  weakened,  and  the  morbid  fears 
and  compulsive  thoughts  act  with  greater  force.  Fatigue 
will  induce  imperative  ideas  in  the  predisposed.  The  writer 
has  known  several  students  whose  minds  were  always 
dominated  during  examinations  by  imperative  ideas,  which, 
however,  quickly  disappeared  or  became  insignificant  when 
the  special  period  of  stress  was  over.  Nevertheless,  it  must  be 
borne  in  mind  that  a  temporary  condition  may  become  more 
permanent ;  and  it  is  well  not  to  treat  too  lightly  mental 
disturbances,  however  trivial,  when  they  occur  in  unstable 
persons. 

Varieties. — There  are  many  kinds  of  imperative  ideas  ;  the 
more  common  ones  will  be  referred  to  when  describing  the 
mental  symptoms.  Westphal  has  divided  obsessions  into 
three  divisions  :  (a)  Those  which  are  almost  entirely  con- 
nected with  thoughts,  such  as  folie  du  doute,  when  they  take 
the  form  of  questions  ;  [b]  those  which  give  rise  to  certain 
actions  ;  (c)  impulsive  obsessions,  which  occasion  immediate 
action  without  results  being  weighed.  Other  writers  divide 
imperative  ideas  into  motor  and  sensory  varieties  ;  the  motor 
taking  the  form  of  touching  things  and  the  like  ;  and  the 
sensory,  ideas  such  as  the  association  of  colours,  smells,  etc., 
with  some  particular  occurrence  or  individual.  Thus,  obses- 
sions may  take  the  form  of  irrepressible  thoughts  or  fears 
(phobias)  and  irresistible  impulses. 

Mental  Symptoms. — Obsessions  of  a  mild  type  are  to  be 
found  in  a  large  number  of  persons,  and  consist  of  such  ideas 
as  the  following  :  '  If  I  do  not  do  such-and-such  a  thing  in 
such-and-such  a  way,  it  will  bring  me  bad  luck,'  or  '  I  must 


PSYCHASTHENIA  295 

wear  tMs  trinket  to-day,  otherwise  some  ill-fortune  may  over- 
take my  son  or  daughter.'  Obsessions  may  appear  purely  in 
actions,  such  as  touching  certain  things  as  they  are  passed  in 
walking,  or  counting  the  footsteps,  or  walking  on  the  cracks 
in  the  pavement,  or  trying  to  avoid  them  and  keeping  only 
on  the  flags  themselves.  Turning  off  the  gas  at  night  has 
already  been  alluded  to  as  a  common  type  of  imperative  idea. 
The  above  are  so  frequently  met  with  that  they  can  scarcely 
be  looked  upon  as  pathological,  for  they  in  no  way  interfere 
with  the  daily  Ufe  of  the  persons  suffering  from  them. 

Somewhat  more  serious  ideas  are  the  various  dreads  not 
infrequently  observed.  The  dread  of  large  open  spaces  (agora- 
phobia), or  closed  spaces  (claustrophobia),  or  the  fear  of  being 
in  high  places  (acrophobia),  and  the  nervous  dread  of  certain 
animals  or  insects  (zoophobia).  Another  type  of  obsession 
is  the  constant  dread  of  a  sudden  impulse  to  use  blasphemous 
or  other  wrong  expressions  (coprolaha).  This  type  of  im- 
perative idea  may  seriously  affect  the  life  and  conduct  of  the 
sufferer,  as  he  not  infrequently  withdraws  himself  from  society 
on  account  of  the  ever-present  dread.  When  the  above- 
mentioned  fears  become  marked,  they  slowly  usurp  the  whole 
attention  of  the  patient.  The  woman  who  is  in  constant 
dread  of  fleas  spends  her  whole  time  in  searching  her  clothes 
for  these  insects ;  she  asks  that  her  garments  may  be  fumi- 
gated ;  she  will  not  sit  down  on  any  seat,  lest  perchance  a 
flea  may  be  upon  it.  A  condition  closely  allied  to  this  is  the 
perpetual  fear  of  some  dirt  (myscophobia)  or  contagion  ;  this 
patient  wiU  always  be  washing  himself  and  cleansing  the 
various  utensils  and  dishes  from  which  he  takes  his  food.  The 
man  w^ho  dreads  open  or  closed  spaces  may  become  very 
agitated  whenever  he  finds  himself  in  one,  and  he  may  rapidly 
become  sick  and  faint.  The  writer  knows  a  man  who  has 
been  fined  several  times  for  stopping  an  express  train,  the 
cause  of  his  doing  so  on  each  occasion  being  the  sudden  fear 
of  being  shut  up  in  the  confined  carriage. 

Another  form  of  imperative  idea  which  is  more  common 
among  business  men  is  the  constant  uncertainty  as  to  whether 
every  letter  has  been  sealed  in  its  proper  envelope.  This  idea 
may  give  rise  to  great  mental  torment ;  such  a  sufferer  may  be 
unable  to  rest  until  he  has  telegraphed  to  his  various  corre- 


296  PSYCHOLOGICAL  MEDICINE 

spondents  to  know  whether  they  have  duly  received  his  com- 
munications. The  fear  of  pins  or  matches  is  a  common  one. 
The  writer  knows  of  the  case  of  a  clergyman  who  has  a  constant 
dread  that  he  may  have  dropped  a  pin  into  a  drinking  cup, 
and  that  inadvertently  he  may  be  the  cause  of  the  death  of 
some  person  who  may  swallow  it.  To  administer  the  Holy 
Communion  is  always  a  source  of  great  anxiety  to  him  through 
the  fear  that  he  may  drop  a  pin  into  the  chalice.  Some  persons 
will  take  several  hours  to  dress  themselves  every  morning,  as 
they  have  to  search  each  article  of  attire  for  pins  or  matches 
before  putting  it  on.  Inquisitiveness  is  another  form  of 
obsession.  In  this  case  the  patient  feels  compelled  to  pry 
into  everythmg  ;  if  he  sees  a  man  reading  a  letter,  he  works 
gradually  towards  him^  until  he  can  read  it  himself.  An 
imperative  idea  such  as  this  not  uncomm.only  leads  to  alter- 
cations with  strangers,  who  object  to  their  private  correspon- 
dence being  made  the  object  of  prying  curiosity.  An  extreme 
instance  of  this  inquisitiveness  was  the  case  of  a  man  who  was 
seen  running  down  the  middle  of  the  Strand  after  a  hansom 
cab  ;  he  had  seen  a  piece  of  paper  which  had  become  attached 
to  the  tyre  and  was  revolving  with  the  wheel,  and  he  felt 
impelled  to  see  whether  there  was  anything  upon  it.  Some 
persons  get  an  imperious  idea  that  they  will  commit  suicide 
or  kill  some  one.  I  have  known  a  patient  with  the  latter 
phobia  drive  to  the  nearest  asylum  one  day  when  the  fear 
obsessed  him.  Irresistible  impulse  also  may  take  the  form 
of  kleptomania,  pyromania,  and  mutilation  of  animals. 

Doubt  may  become  so  prominent  a  factor  in  some  people's 
lives  that  it  must  be  considered  as  an  obsession.  Kehgious 
doubts  are  very  common.  Thoughts  such  as  these  Avill  hamit 
him  :  '  Is  there  really  a  God  ?  '  'Is  there  really  a  Heaven  ?  ' 
'  Does  death  mean  absolute  annihilation  ?  '  Others  will  get 
doubts  as  to  whether  their  body  really  is  their  body.  Again, 
'  Are  things  really  what  they  seem  to  be  ?  '  '  Do  I  really 
love  my  husband  ?  '  Persons  with  these  doubts  often  exhibit 
indecision  in  other  things  in  hfo.  In  its  mildest  form  doubt 
is  nothing  more  than  a  slight  feeling  of  uncertainty  and  a 
desire  for  others  to  decide.  Later  it  becomes  a  more  active 
principle  ;  motives  and  actions  are  weighed  and  weighed  again, 
and  yet  the  mental  state  remains  one  of  indecision.     If  in 


PSYCHASTHENIA  297 

the  end  a  judgment  is  arrived  at,  it  is  no  sooner  acted  upon 
than  the  feeling  of  doubt  again  asserts  itself  and  the  ex- 
pediency of  the  decision  is  questioned.  Such  persons  will 
return  over  and  over  again  and  ask  whether  they  made 
themselves  clear  when  ihej  expressed  a  view  on  some  subject. 
In  some  extreme  cases  this  constant  doubt  with  all  its  ac- 
companying worry  and  distress  so  undermines  the  health  of 
the  patient  that  a  serious  mental  break-down  may  result.  It 
is  impossible  to  recite  eveiy  conceivable  form  of  obsession,  but 
the  above-mentioned  will  be  found  to  be  the  most  common 
examples. 

It  is  now  necessaiy  to  refer  briefly  to  the  general  effect 
that  these  imperative  ideas  have  upon  the  patient.  The 
obsessions  that  appear  in  the  average  person  are  not  im- 
portant, for  they  do  not  seriously  affect  his  intellectual  life. 
They  occur  periodically  and  for  the  time  being  may  give  rise  to 
some  slight  annoyance,  but  the  attention  is  easily  directed  to 
other  things  when  occasion  demands.  On  the  other  hand,  if 
obsessions  constantly  recur,  they  tend  to  become  more  elaborate 
and  organised  and  in  the  course  of  time  usurp  the  whole 
attention.  The  patient  strives  hard  to  put  the  idea  out  of  his 
mind,  but  it  recurs  with  greater  force  and  clustermg  round  it 
with  ever-increasing  numbers  are  the  vague  fears  and  doubts. 
The  ideas  and  fears  form  a  complex,  for  secondary  ideas 
have  become  associated  with  the  primary  idea,  and  any  one 
of  these  ideas  coming  into  consciousness  may  bring  in  the 
whole  complex.  A  psychasthenic  may  be  travelling  com- 
fortably^ in  a  railway  carriage,  talking  with  a  friend  :  the  con- 
versation ceases  for  a  moment  and  suddenly  he  realises  that 
he  is  in  a  train,  and  at  once  the  complex  comes  in  with  all  its 
associated  ideas  and  fears  and  the  man  becomes  bathed  with 
perspiration  owing  to  a  great  sense  of  anguish.  And  so  vv^ith 
all  other  types  of  irrepressible  thought. 

The  next  state  is  one  of  mental  anguish  and  a  feeling  of 
impotence  at  not  being  able  to  remove  the  cause.  For  a  time 
the  struggle  may  continue,  but  soon  the  agitation  of  mind  sets 
up  physical  disturbances  and  the  restlessness  may  be  intense. 
At  last  the  patient  obeys  the  dictate  of  his  thought,  whatever 
it  may  be.  The  action  gives  rise  to  a  sense  of  mental  cahn, 
which  is  only  ruffled  by  slight  feehngs  of  depression,  brought 


298  PSYCHOLOGICAL  IVIEDICINE 

about  by  the  knowledge  of  the  impotence  of  the  will  to  over- 
come the  obsession.  For  the  moment  the  imperative  idea 
is  satisfied,  but  the  mental  peace  is  of  short  duration.  Before 
long  the  imperious  thought  has  again  returned,  and  a  renewed 
struggle  begins.  The  knowledge  of  ultimate  submission  adds 
to  the  mental  torment  of  the  patient,  who  accordingly  braces 
himself  to  resist  to  the  utmost.  Again  he  fails,  and  again  the 
obsession  is  satisfied  ;  the  greater  the  effort  that  has  been 
made  to  conquer,  the  greater  is  the  sense  of  relief  which  follows 
the  relinquishment  of  the  contest. 

Consciousness  is  clear  thi'oughout  ;  the  patient  reahses  the 
whole  position  and  will  freely  tell  his  troubles  to  others  ;  he 
admits  the  folly  of  the  whole  situation  and  cannot  understand 
why  he  is  not  able  to  cast  aside  his  foolish  thoughts.  The 
emotional  attitude  varies  in  different  cases,  but  there  is  usually 
some  depression  occasioned  by  the  continual  failm'e  to  over- 
come the  obsession,  and  in  some  instances  this  depression 
may  become  so  severe  as  to  necessitate  asylum  treatment. 
Nevertheless  in  the  great  majority  of  cases  imperative  ideas 
do  not  result  in  insanity.  The  memory  is  usually  excellent, 
but  the  powers  of  observation  may  be  limited,  as  the  whole 
attention  may  be  occupied  by  the  obsession.  Psychomotor 
hallucinations  and  hallucinations  of  sight  in  the  hypnagogic 
state  occur  in  a  small  number  of  these  cases.  Expectancy 
may  produce  illusions  but  these  are  readily  recognised  by  the 
patient.  Attempts  at  self-destruction  are  very  rare,  but  when 
the  imperative  ideas  are  so  distressing  and  continuous  as  to 
render  the  life  of  the  patient  a  brnxlen  to  himself,  the  danger 
of  suicide  must  not  be  overlooked. 

Physical  Symptoms. — The  circulation  is  usually  defective 
and  the  pulse  tension  is  abnormally  low  and  many  patients 
are  anaemic.  Menorrhagia  or  metrorrhagia  is  common  in 
psychasthenic  women.  In  the  milder  forms  of  this  malady  the 
general  health  of  the  patient  does  not  suffer  to  any  marked 
extent,  \mt  when  the  oljsessions  are  constantly  recurring  the 
continual  worry  may  seriously  undermine  the  bodily  strength. 
In  that  event  the  weight  falls  and  the  various  systems  of  the 
body  become  disordered. 

Prognosis. — The  disease  tends  to  run  a  very  chronic 
course.     Imperative    ideas    are    always    more    marked    when 


PSYCHASTHENIA  299 

the  general  health  is  bad,  and  after  physical  improvement  has 
taken  place  they  may  almost  disappear  for  a  time  or  become 
so  feeble  as  only  slightly  to  affect  the  habits  of  the  patient. 
The  prognosis  is  much  more  favom:able  if  the  obsessions  are 
of  recent  origin.  Habits  of  thought  and  action  detrimental 
to  the  prospect  of  recovery  are  quickly  formed.  Occasionally 
the  annoyance  is  so  great  that  rapid  physical  deterioration 
results,  and  with  increasing  bodily  weakness  the  mental 
torment  becomes  more  unbearable.  Many  patients  remain  in 
fair  health,  but  are  unable  to  follow  their  customary  occupa- 
tions, as  the  attention  is  constantly  engaged  with  the  obsession. 
Treatment. — In  every  case  it  is  wise  carefully  to  explain 
to  the  patient  that  obsessions  are  a  most  common  complaint 
and  that  the  majority  of  persons  suffer  from  them  in  a  mild 
way.  If  the  sufferer  is  seen  in  the  early  days  of  the  com- 
plaiat,  warn  him  against  forming  habits  and  being  governed 
by  habit.  Many  obsessions  are  based  upon  some  habit  which 
caimot  be  displaced,  the  patient  feeling  that  the  habit  is  of 
such  long  standing  that  it  would  be  tempting  Providence  to 
make  any  change.  A  timely  warning  will  do  much  for  such  a 
man,  as  it  may  prevent  him  from  nursing  ideas  which,  if 
encouraged,  may  become  the  ruling  motives  of  his  life.  In  those 
cases  where  the  physical  health  is  bad  the  patient  should  be 
kept  in  bed  for  a  few  weeks  and  fed  on  a  nourishing  diet.  The 
general  bodily  condition  must  always  be  attended  to,  for  the 
better  the  health  the  better  the  powers  of  control  and  resistance. 
Diversion  and  exercise  in  the  open  air  will  do  more  than  the 
will  power  m  dispersing  the  tormenting  thoughts.  Hypnosis 
has  been  tried  in  the  treatment  of  imperative  ideas,  but  the 
results  are  very  disappointing.  Some  authorities  claim  to 
have  had  success,  but  others  condemn  it  as  useless.  Much 
can  be  done  by  a  patient  physician  who  is  able  to  spend  time 
daily  in  reassuring  the  invahd  and  explaining  to  him  the  nature 
of  his  illness.  Freud's  method  of  psycho-analysis  is  useful 
in  bringing  about  the  recovery  in  some  cases  ;  this  special 
form  of  treatment  is  referred  to  in  the  special  chapter  on 
Treatment. 


800  PSYCHOLOGICAL  MEDICINE 


CHAPTER  XVIII 

THE  MORE  COMMON  NEUROSES:  PSYCHO-NEUROSES 
OCCURRING  IN  MEN  EXPOSED  TO  SHELL-SHOCK 
AND    STRAIN    OF    WAR 

There  is  little  doubt  that  in  the  past  neuroses  and  psycho- 
neuroses  have  not  taken  the  place  in  medicine  which  they 
ought  to  have  taken.  So-called  '  nerves  'were  regarded  as  a 
form  either  of  malingering  or  over-fussiness  from  which  the 
patient  could  easily  recover  if  he  wished.  It  is  true  that  the 
increase  of  nerve  exhaustion  cases  was  beginning  to  attract 
attention  before  1914,  but  it  is  this  terrible  war,  entailing  as 
it  does  enormous  mental  and  physical  strains  upon  vast  numbers 
of  men  and  women  of  every  grade,  that  has  forced  upon  the 
medical  profession  a  more  careful  study  of  these  states.  In  the 
future  this  subject  will  held  the  important  place  in  medicine 
that  it  rightly  deserves. 

Neurasthenia  and  nervous  debility  have  usually  been  treated 
by  the  general  physician,  and  there  has  been  a  great  gulf  between 
these  and  the  more  serious  types  of  mental  disorder.  Some  per- 
sons would  almost  have  us  believe  that  a  physician  experienced 
in  mental  diseases  was  unsuited  for  directing  the  treatment 
of  nerve  exhaustion  states ;  I  presume  on  the  basis  that  he 
might  see  mental  symptoms  where  there  were  none.  It  is 
almost  impossible  to  understand  such  an  argument :  there 
can  be  no  such  refinements  in  functional  nervous  diseases. 
The  mental  attitude  of  the  j^atient  must  always  be  the  deter- 
mining factor  in  these  cases,  whether  he  is  obsessed  by  a  fear 
or  suffering  from  a  tic,  palsy,  or  other  physical  phenomenon. 
Therefore  to  understand  a  case  of  functional  nervous  disorder 
the  physician  must  understand  the  workings  of  the  mind  in 
health  and  disease.  If  he  does  not  understand  these,  he  is 
without  much  of  the  data  by  which  he  can  form  an  opinion 
on  the  course  of  any  given  case  ;    he  fails  to  appreciate  the 


.       NEUROSES  AND  PSYCHO-NEUROSES  301 

dangers  to   be  avoided,   and  he  will    be  constantly  making 
errors  in  diagnosis  and  prognosis. 

The  equipment  of  hospitals  for  these  nerve  cases  must  have 
been  a  severe  tax  upon  the  administration,  and  it  speaks  highly 
for  the  efficiency  of  the  medical  service  that  so  much  has  already 
been  done.  At  the  beginning  of  the  war  the  Director- General 
of  Army  Medical  Services  was  faced  with  the  problem  of  supply- 
ing hospitals  for  great  numbers  of  these  nerve  and  shock  cases 
in  varying  degrees  of  severity,  and  the  difficulty  has  been  largely 
overcome.  Nevertheless  there  is  much  to  be  done,  especially 
in  training  medical  men  to  understand  these  cases  and  to  learn 
how  to  treat  them.  Old  views  must  be  thrown  over,  and  patients 
must  not  be  treated  as  malingerers  until  definite  proof  of 
this  is  forthcoming.  For  it  is  more  than  unfair,  it  is  wrong,  to 
cover  one's  ignorance  of  a  nervous  or  mental  state  by  falsely 
charging  a  patient  with  feigning  his  symptoms. 

In  the  following  pages  an  attempt  will  be  made  briefly  to 
describe  some  of  the  more  common  types  of  disorder  in  nerve 
shock  and  nerve  exhaustion  cases,  together  with  the  more 
serious  mental  disorders  which  arise  under  certain  conditions, 
and  brief  reference  will  be  made  to  the  several  forms  of  treat- 
ment employed  in  these  various  cases. 

In  discussing  nerve  cases  the  question  has  always  been  as 
to  whether  the  condition  was  purely  a  disorder  of  function, 
or  whether  it  was  caused  by  some  organic  change  in  the  nervous 
system  itself.  Time  will  prove  whether  this  differentiation 
will  have  to  be  modified.  Already  French  observers  have 
reported  that  shell-shock  cases  examined  in  field  hospitals 
within  a  very  short  time  of  the  concussion  exhibit  symptoms 
which  in  the  past  have  been  regarded  as  pathognomic  of 
organic  disease.  Such  symptoms  are  the  plantar  extensor 
reflex,  absent  knee-jerk,  and  absent  cutaneous  reflexes  and 
anaesthesise,  excess  of  cerebro-spinal  fluid,  and  the  fact  that 
it  contains  albumen  or  an  excess  of  lymphocytes.  It  is 
further  observed  that  these  symptoms  as  a  rule  rapidly  dis- 
appear or  may  be  replaced  by  tics,  twitching,  spasms,  etc. 
Therefore  some  of  the  evidence  would  point  to  the  original 
damage  being  organic,  and  that  later  the  symptoms  arise 
which  have  in  the  past  been  spoken  of  as  functional.  In 
other  words,  after  the  severe  shock  symptoms  have  passed  off 


302  PSYCHOLOGICAL  MEDICINE 

there  may  be  what  has  been  called  ^  '  residuum  '  left.  Now 
it  is  probable  that  either  an  exhausted  nervous  system  or  intense 
emotional  tone  determines  this  '  residuum.'  In  civil  life  this 
is  certainly  met  with  ;  for  example,  several  persons  may  witness 
a  bad  street  accident  or  other  distressing  sight,  and  although 
upset  at  the  moment,  most  of  them  are  able  to  repress  it  out 
of  their  mind  or  forget  it,  but  if  one  of  them  is  a  nervously 
exhausted  person,  it  may  be  impossible  for  him  to  dissociate 
the  incident  from  his  thoughts,  and  it  may  remain  a  factor 
which  affects  both  his  waking  and  sleeping  consciousness. 
Dejerine  has  suggested  that  some  antecedent  emotional  con- 
dition is  to  be  found  in  most  cases  of  neurasthenia,  but  the 
"vvTiter  beheves  that  the  experience  of  this  war  may  modify 
this  opinion.  Hurst  regards  many  of  the  so-called  functional 
symptoms  which  arise  within  a  short  time  after  the  concussion 
during  the  period  of  treatment  of  shell-shock  as  secondary 
auto-suggestions.  For  example,  a  man  who  has  been  buried 
and  concussed  at  the  same  time  may  on  regaining  consciousness 
find  that  it  is  impossible  to  call  out,  and  then  he  gets  the  terror- 
stricken  behef  that  he  is  dumb,  and  such  a  one  may  remain  mute 
until  he  is  properly  treated.  The  writer  has  knoT^n  the  case 
of  a  soldier  ^\ho  was  severely  concussed  and  as  a  result  had 
marked  weakening  of  muscular  movement.  He  was  seen  by  a 
medical  man,  who  was  imcertain  in  his  mmd  as  to  whether 
the  condition  was  not  likely  to  become  permanent,  and  he 
conveyed  his  fear  to  his  patient,  who  rapidly  became  weaker  and 
remained  paralysed  for  several  weeks  until  the  original  impres- 
sion was  removed. 

The  following  are  the  more  common  disturbances  found  in 
shock  cases.  There  may  be  a  partial  or  complete  loss  of  con- 
sciousness which  lasts  a  varying  period  from  minutes  to  days.  It 
has  been  noted  that  vision  nearly  always  returns  before  speech. 
Usually  the  memory  is  good  up  to  the  time  of  the  explosion, 
after  which  there  is  a  hiatus,  or  there  may  be  a  period  of  amnesia 
preceding  the  injury.  The  writer  has  known  a  case  of  an  officer 
whose  memory  remains  a  blank  from  the  day  before  he  left 
England  Avith  the  expeditionary  force  until  a  fortnight  after 
his  return  to  this  country.  The  memory  may  rapidly  return, 
or  the  recovery  may  be  slow  or  imperfect.  On  regaining 
consciousness  the  patient  may  remain  dumb  or  blind,  or  these 


NEUROSES  AND  PSYCHO-NEUROSES  303 

symptoms  may  develop  later.  Although  able  to  speak,  the 
patient  may  be  fomid  to  have  a  stammer  or  hesitancy  of  speech. 
This  condition  not  uncommonly  comes  on  during  the  period 
that  the  patient  is  under  treatment,  especially  if  he  is  warded 
with  other  patients  who  are  suffering  from  a  speech  defect. 
Deafness  is  also  common.  In  some  instances  there  has  been 
damage  to  the  drum  of  the  ear,  and  there  may  be  haemorrhage. 
Even  in  these  cases  it  is  extraordinary  how  rapid  may  be  the 
recovery.  On  the  other  hand,  the  deafness  may  persist. 
Tinnitus  is  a  frequent  sequel  to  shell  concussion,  and  it  may 
persist  for  long  periods  or  indeed  may  never  really  clear  up. 
Intolerance  to  sound  is  another  common  and  trying  symptom  ; 
this  is  especially  present  in  those  cases  which  have  suffered 
from  severe  mental  strain  in  addition  to  the  concussion. 

Headaches  are  extremely  common  and  may  be  frontal  or 
occipital,  or  a  bruised  feeling  on  the  top  of  the  head  may  be  the 
description  given  of  the  pain.  Others  complain  of  a  sensation 
of  fullness  in  the  head,  as  if  it  would  burst.  The  headache 
may  be  continuous  at  first  and  later  it  may  recur  several  times 
a  day,  more  especially  with  exertion  or  during  conversation. 
This  symptom  may  last  for  several  months,  or  if  untreated, 
for  years.  It  is  the  symptom  which  frequently  causes  a  relapse 
on  the  return  of  the  soldier  to  his  military  duties  ;  he  complains 
that  he  can  no  longer  endure  noise  or  fatigue  and  that  the  sound 
of  gun-fire  is  physically  unbearable  to  him. 

The  disorders  of  movement  are  many  and  varied.  There 
may  be  total  or  partial  paralysis  which  passes  off  rapidly  or 
slowly,  or  the  condition  may  be  one  of  hemiplegia  or  merely  a 
general  sense  of  weakness.  This  weakness  may  be  physical 
in  origin,  or  it  may  be  based  upon  a  psychical  condition.  Every- 
one has  experienced  a  loss  of  motor  power  when  suddenly  told 
some  bad  news  or  other  disturbing  information  ;  for  the  moment 
such  a  one  feels  all  the  power  go  out  of  his  legs  and  he  may  have 
to  sit  down  to  save  a  collapse.  Now  imagine  the  mental  strains 
and  shocks  that  the  men  serving  at  the  front  are  daily  exposed 
to,  and  the  surprise  will  not  be  that  there  are  these  cases  but 
that  there  are  not  more  of  them. 

In  other  cases  there  are  marked  tremors  or  shaking  ;  these 
may  be  continuous  during  waking  consciousness,  or  they  may 
only  be  discernible  during    movement.     Some  patients  throw 


304  PSYCHOLOGICAL  J^IEDICINE 

themselves  into  violent  paroxysms  when  asked  to  perform 
certain  movements  such  as  walking.  To  the  mitrained  mind 
this  may  seem  very  closely  alhed  to  malingering,  if  not  true 
malingering.  Of  course  there  is  no  doubt  that  a  very  small 
percentage  of  these  cases  are  feigned  disorders,  but  the  writer  is 
equally  convinced  that  the  number  is  small,  and  that  if  care  is 
taken  they  are  readily  discovered  ;  in  any  case  before  making 
this  diagnosis  every  care  must  be  taken,  and  the  mental  aspect 
mui>t  not  be  overlooked. 

Twitching  and  spasms  are  very  common,  and  they  frequently 
develop  during  the  convalescent  stage.  Contracture  also  occurs 
in  some  cases. 

In  all  these  disorders  of  movement  it  is  very  important  to 
eliminate  any  possible  focal  lesion  before  deciding  that  the 
condition  is  a  functional  one. 

If  there  has  been  any  cutaneous  or  deep  anaesthesia  in  a 
shock  case,  the  recovery  may  be  rapid  or  slow  ;  as  a  rule  this 
varies  with  the  severity  of  the  concussion. 

Tachycardia  is  another  symptom  which  is  at  times  very 
noticeable,  and  it  usually  leads  to  the  patient  being  very 
restless.  In  other  cases  the  pulse  rate  is  abnormally  slow 
and  remains  infrequent  for  several  weeks  or  months. 

The  body  weight  frequently  falls,  at  times  more  than  a  stone, 
after  a  severe  nerve  shock  or  concussion,  and  so  long  as  it 
remains  low,  the  patient  is  seldom  fit  to  resume  his  duties, 
and  if  he  tries  to  do  so,  he  usually  breaks  down  again  almost 
at  once.  Nausea  and  sickness  may  occm-  and  is  often  a 
cause  of  loss  of  weight. 

To  pass  on  to  consider  the  mental  disorders  met  with  in 
service  men.  It  may  be  at  once  stated  that  there  are  no  new 
disturbances  observable  which  do  not  occur  in  civil  hfe.  But 
the  great  number  of  acute  and  recent  cases  which  arise  have 
made  it  easy  to  study  the  changes  in  very  early  stages,  and  as 
the  men  are  under  miUtary  control  and  can  be  ordered  at 
once  into  hospital,  it  has  been  possible  to  see  what  effect  early 
and  thorough  treatment  has  compared  with  that  which  is 
delayed  and  inefficient.  At  the  outset  it  may  be  stated  that 
persons  who  have  previously  had  a  nervous  break-do^vn  are 
specially  liable  to  a  relapse  under  the  severe  physical  and  mental 
stresses  of  a  war  of  such  a  nature  as  the  present  European  con- 


NEUROSES  AXD  PSYCHO-NEUROSES  305 

flict.  Therefore  vre  see  many  who  have  come  into  this  class, 
and  the  writer  may  here  mention  in  passmg  that  when  such 
persons  break  clown  and  have  to  be  invalided  from  the  service, 
in  his  opinion  too  much  stress  should  not  be  put  upon  the 
original  illness  to  the  detriment  of  the  man's  claims  for  con- 
sideration of  monetary  aid  if  incapacitated  in  the  future  from 
earning  a  livelihood.  This  is  especially  the  case  if,  as  may  have 
happened,  such  a  man  declared  his  tendency  and  weakness 
before  being  accepted  for  service.  Because  a  man  has  had 
one  break-do^m  in  his  life,  it  by  no  means  follows  that  he  will 
have  another,  provided  that  he  lives  wdthm  the  limits  of  his 
nervous  powers.  Therefore  if  called  upon  to  serve  notwith- 
standing his  tendencies  to  fatigue  on  the  nerve  side,  he  is 
taking  an  excessive  risk,  and  that  he  did  so  voluntarily  is  to 
his  credit  and  should  be  recognised,  but  if  under  compulsion 
the  penalty  should  be  met  by  the  country  who  called  upon 
him  to  take  those  risks. 

Mental  symptoms  may  arise  either  as  a  result  of  shock  and 
concussion,  as  in  the  case  of  direct  damage  by  shell  explosion, 
or  as  frequently  happens,  the  exhaustion  is  the  result  of  a 
prolonged  strain  wdth  little  or  no  sleep,  or  a  deficiency  of 
food.  The  symptoms  in  the  earlier  stages  or  milder  forms 
are  closely  alHed.  They  are  irritability  and  loss  of  power  of 
concentration,  and  with  this  the  memory  becomes  defective, 
especially  for  recent  events.  Some  of  the  cases  are  mildly 
depressed.  At  the  same  time  there  is  a  general  loss  of  energy 
and  a  diminished  capacity  to  carry  out  duties.  A  man  will 
lose  his  self-reliance  and  his  judgment  becomes  impaired, 
and  he  may  be  the  victim  of  all  kinds  of  fears.  It  is  also 
worthy  of  note  that  fears  w^hich  he  may  have  had  for  many 
years  now  appear  to  be  realities,  and  he  wall  weave  long  stories 
in  order  to  prove  the  correctness  of  his  judgment  in  so  regarding 
them.  He  is  not  infrequently  emotional,  and  may  break  down 
and  weep.  His  inability  to  make  a  decision  is  a  trying  symptom, 
and  in  the  case  of  ofiicers  this  is  not  uncommonly  one  of  the 
most  noticeable  features.  Severe  shock  and  exhaustion  affect 
a  patient's  control,  and  as  sequehe  there  may  be  alterations 
in  his  conduct  and  manner.  Certain  persons  have  tendencies, 
usually  inherited  or  instinctive,  and  these  maybe  held  in  control, 
but  remove  that  control  and  the  tendency  wdll  declare  itself  ; 

20 


306  PSYCHOLOGICAL  MEDICINE 

alcohol  or  se*xual  faults,  extravagance  and  general  reckless- 
ness are  amongst  the  more  common  failings. 

In  some  instances  there  is  marked  restlessness,  and  as  time 
passes  the  patient  becomes  mentally  confused.  Insomnia  is  as  a 
rule  a  prominent  symptom,  and  when  present  leads  to  a  rapid 
increase  of  all  other  symptoms.  The  sleep  is  not  only  defective 
in  quantity,  but  the  quality  of  that  which  the  patient  gets  is 
bad.  He  dreams  distressing  dreams  and  awakes  frequently 
with  panics  and  terrors  of  all  sorts.  He  may  talk  and  call 
out  in  his  sleep  and  even  strike  out  if  anyone  goes  near  him, 
for  at  the  moment  his  thoughts  may  be  back  on  the  battle- 
field and  he  treats  those  who  come  near  him  as  his  enemy. 
Some  patients  do  not  stay  in  bed  and  will  wander  about  the 
room,  and  care  should  be  taken  in  approaching  such  a  one 
until  he  is  fully  awake. 

Under  these  conditions  hallucinations  and  illusions  of  sight 
are  common  and  are  not  necessarily  a  serious  symptom,  as 
with  treatment  the  disordered  state  rapidly  improves. 

The  writer  has  already  referred  to  the  loss  of  memory  which 
may  result  from  a  severe  concussion,  and  reference  has  been 
made  to  the  headaches  which  are  usually  present  in  all  exhaus- 
tion and  shock  cases. 

The  above  may  be  the  whole  of  the  mental  disturbances,  and 
if  suitable  treatment  is  given  the  progress  of  the  case  is  steadily 
towards  recovery,  although  in  some  cases  the  convalescence  is  a 
long  one.  If,  on  the  other  hand,  the  exhaustion  or  concussion  is 
a  very  severe  one,  or  the  patient  is  a  predisposed  person  either 
as  a  result  of  inherited  tendencies  or  on  account  of  a  former 
break-down  or  head  injury,  the  symptoms  may  be  more  marked 
and  greater  in  number. 

The  feeling  of  mental  eftort  passes  on  into  one  of  confusion. 
There  is  dissociation  and  inability  to  carry  on  a  connected  con- 
versation. Hallucinations  of  sight  and  hearing  are  common. 
'  Voices  '  scoff  at  him,  and  he  hears  disparaging  remarks  made. 
These  sensory  disturbances  are  at  first  appreciated  by  the 
patient  to  be  subjective  in  character.  He  feels  alarmed  and 
fears  that  he  may  be  losing  his  reason.  Later  he  is  certain  that 
they  are  external  in  origin  and  that  in  reality  he  is  the  victim 
of  some  great  and  vile  conspiracy.  At  first  he  tries  to  escape 
from  his  persecutors  by  moving  from  place  to  place,  or  he  asks 


NEUROSES  AND  PSYCHO-NEUROSES  307 

for  the  charge  against  him  to  be  inquired  into.  Later  he  may 
become  suicidal,  or  dangerous  to  his  would-be  accusers.  During 
this  time  the  sleep  has  become  increasingly  bad,  his  body  weight 
has  fallen,  and  the  patient  has  an  anxious  and  over-strained 
appearance.  The  headaches  which  were  originally  severe  at 
the  top  and  back  of  the  head,  are  replaced  by  a  dull  negative 
sensation  in  the  brain,  and  conversation  is  impossible  or  only 
carried  on  with  difficulty,  and  the  patient's  conduct  becomes 
unreliable  and  he  acts  on  impulse.  In  some  cases  there  is 
a  condition  of  stupor  of  varying  degrees,  from  one  of  marked 
confusion  to  complete  clouding  of  consciousness.  For  a  more 
complete  description  of  the  condition  the  reader  is  referred 
,  to  the  chapter  on  Confusional  Insanity. 

The  exhaustion  psychoses  are  by  far  the  most  common  which 
are  met  with,  and  this  is  what  would  be  expected,  having 
regard  to  the  nature  of  the  strains. 

Fortunately  many  of  the  cases  are  quite  mild  and  readily 
recover  if  given  time  and  appropriate  treatment,  and  if  the 
treatment  is  persisted  in  until  recovery  has  taken  place. 

On  the  other  hand,  some  cases  run  a  sub-acute  course,  and  a 
general  hyper-sensitivity  of  the  nervous  system  is  the  pre- 
dominant symptom.  It  shows  itself  by  mental  irritability 
and  a  steadily  increasing  irritability  of  the  cerebral  and  spinal 
reflexes.  In  fact  the  latter  is  largely  responsible  for  the  former, 
and  it  is  because  the  patient  is  so  easily  startled  that  the 
personality  becomes  disturbed.  It  does  not  seem  to  be  always 
appreciated  how  important  is  this  hyper-sensitivity,  and  how 
it  may  be  the  chief  factor  in  determining  a  nerve  exhaustion 
break-down.  Some  of  these  patients  develop  epileptic  fits, 
and  whenever  the  reflexes  become  very  over-active,  it  is  always 
well  to  guard  against  seizures  by  prophylactic  treatment. 

The  other  forms  of  mental  disorder  met  with  do  not  here 
call  for  special  mention,  as  they  are  fully  described  in  other 
chapters  of  this  book.  The  break-down  may  have  little  or 
nothing  to  do  with  war  conditions  more  than  that  strain  may 
hasten  on  the  disease,  as  in  general  paralysis,  dementia  prsBCox, 
or  maniacal-depressive  states.  Alcohol  acts  with  special  force 
in  those  who  have  had  head  injuries — concussion  and  the  like — 
and  small  amounts  may  give  rise  to  serious  symptoms. 

The  prognosis  is  favourable  in  most  of  the  cases  in  which  the 


308  PSYCHOLOGICAL  MEDICINE 

exhaustion  or  strain  is  a  recent  one,  and  where  proj^er  treatment 
has  been  carried  out.  Symptoms  frequently  2)ass  over  quickly 
and  the  patient  appears  to  have  regained  his  normal  state,  and 
the  danger  is  that  he  is  either  permitted  to  leave  the  hospital, 
or  he  is  sent  away  to  the  care  of  his  friends  where  he  tries 
to  lead  an  ordinary  life,  or  some  cases  return  to  duty.  Many 
of  these  patients  relapse.  As  one  would  expect,  exhaustion 
cases  quickly  improve  and  readily  relapse,  and  herein  is  the 
danger,  unless  there  is  some  definite  principle  underlying  the 
methods  of  treatment.  Face  value,  or  what  a  person  appears 
to  be  on  a  superficial  examination,  is  a  more  than  unreliable 
test  in  investigating  fatigue  states.  A  person  may  appear 
normal,  and  yet  his  sleep  may  be  disturbed  by  terrifying  dreams; 
or  he  may  be  constantly  haunted  by  the  horrible  scenes  he  has 
already  witnessed.  He  may  appear  to  be  in  rude  physical 
health,  and  yet  the  slightest  noise  may  produce  an  intolerable 
headache.  Further,  if  a  man  has  already  broken  down  in  his 
military  duties,  he  may  still  remain  obsessed  by  the  fear  that 
if  he  returns  he  will  disgrace  himself  and  his  regiment.  It  is 
certain  that  so  long  as  night  terrors  occur  there  is  no  recovery, 
and  the  same  may  be  said  of  headaches,  or  severe  losses  of  weight, 
loss  of  power  of  concentration,  irritability,  or  restlessness.  The 
pulse  rate  is  also  helpful  in  arriving  at  a  proper  decision. 

In  those  cases  where  there  is  a  functional  loss  of  speech, 
sight,  hearing,  etc.,  a  sudden  shock  may  lestore  the  patient. 
This  is  equally  true  of  many  mental  states,  as  is  not  uncommonly 
observed  in  mental  hospitals.  This  probably  indicates  that 
the  original  disorder  which  gave  rise  to  the  secondary  sensory 
disturbance  has  recovered,  and  in  consequence  any  stimulus 
may  remove  the  secondary  symptom.  It  is  on  this  account 
that  varied  cults  have  their  successes.  To  make  a  mute  man 
speak  or  a  blind  man  see  are  startling  results,  but  too  great 
claims  must  not  be  made  foi'  the  means  used,  as  it  will  be 
only  one  of  many  Vv'hich  is  successful.  A  soldier,  mute  as  the 
result  of  shell-shock,  has  regained  his  power  of  speech  through 
being  given  the  wrong  change  at  a  railway  booking-office. 

Treatment. — The  first  treatment  in  functional  neuroses 
and  psychoses  is  the  same  as  in  all  acute  conditions,  i.e.  to 
give  rest.  Now  the  rest  must  be  both  pliysical  and  mental, 
and  herein  hes  the  difficulty.    Can  it  be  expected  that  a  man 


NEUROSES  AND  PSYCHO-NEUROSES  309 

with  a  highly  irritable  nervous  system.,  whom  the  least  noise 
distresses,  can  obtain  rest  or  sleep  in  a  ward  or  dormitory. 
Single  rooms  are  absolutely  necessary,  not  only  to  give  the 
patient  a  proper  chance  of  quiet  and  sleep,  but  to  prevent 
the  risk  of  his  acquiring  any  tics,  spasms,  or  similar  habits  from 
other  patients.  It  is  true  that  some  patients  do  not  do  well 
if  isolated,  but  isolation  is  not  necessary  so  long  as  those  visiting 
him  are  wise  persons.  Apportion  out  the  day  so  that  the  patient 
has  his  treatments,  v/hatever  they  may  be,  in  the  morning, 
a  proper  rest  after  the  mid-day  meal,  and  then  the  visitors, 
never  more  than  two,  before  six  in  the  evening.  The  days 
pass  easily,  the  patient  has  not  time  to  be  introspective,  and 
yet  he  is  not  fatigued,  or  if  such  happens  to  result,  the  visiting 
must  be  lessened  according  to  requirements. 

It  is  clear  that  patients  Avill  take  varying  times  to  recover  ; 
this  depends  upon  the  severity  of  the  emotionally  toned 
stress  and  the  state  of  the  person  as  regards  fatigue  at  the 
time  the  stress  w^as  operative.  In  the  case  of  fears,  it  is  some 
time  before  the  memory  regarding  them  fades. 

The  medicinal  treatment  is  chiefly  confined  to  giving 
sedatives.  The  writer  has  found  from  experience  that  bromides 
are  beneficial  in  practically  all  cases,  but  it  is  advisable  to 
rely  upon  small  doses  long  continued  rather  than  to  give  the 
larger  quantities.  Five  to  ten  grains  of  potassium  bromide 
once  a  day  is  ample  to  dull  the  reflexes,  and  as  these  become 
less  active  so  the  personality  of  the  patient  is  less  and  less 
disturbed.  Insomnia  should  be  treated  at  once,  and  the  most 
reliable  drug  is  sodium  veronal  or  medinal  in  seven  to  ten 
grain  doses  at  bedtime. 

Losses  of  weight  and  other  symptoms  are  to  be  prescribed 
for  in  the  usual  way.  As  regards  special  treatment,  in  some 
cases  massage  is  helpful,  but  it  will  be  found  that  it  is 
inadvisable  in  highly  exhausted  or  irritable  patients. 

Baths  in  various  forms  are  helpful  in  allaying  restlessness.. 
I'or  palsies  special  medical  exercises  should  be  ordered.  In 
some  cases  electrical  treatment  is  valuable.  Mutism  and  dis- 
orders of  speech  can  be  treated  in  various  ways  ;  many  patients 
recover  with  rest  alone  :  others  improve  quickly  on  receiving 
special  breathing  and  phonation  exercises.  It  must  be  borne 
in  mind  that  the  reason  that  many  of  these  persons  remain 


310  PSYCHOLOGICAL  MEDICINE 

mute  is  that  they  are  not  aware  that  they  can  speak ;  for 
the  time  being  they  are  raider  the  beUef  that  the  power  of 
speech  has  gone,  therefore  the  treatment,  whatever  it  may 
be,  should  be  directed  towards  removing  this  impression  which 
at  the  moment  holds  the  patient.  This  also  is  true  of  many 
other  defects  in  sensation  and  movement. 

Hypnotic  suggestion  has  proved  of  value  in  ^ome  cases  ; 
also  it  is  claimed  that  psycho-analysis  has  been  employed 
with  success,  but  the  Amter  has  not  been  impressed  by  the 
results  he  has  seen  of  this  form  of  treatment. 

When  the  patient  passes  into  the  convalescent  stage,  it 
is  important  to  bear  in  mind  that  recovery  is  by  no  means 
assured  unless  some  method  of  treatment  is  persisted  in. 
In  a  number  of  cases  to  return  a  patient  to  his  friends  at  this 
stage  is  either  courting  relapse  or  retarding  recovery.  The 
laj^man's  idea  of  treating  any  nervous  or  mental  state  is  to  cheer 
up  the  patient,  and  consequently  the  latter  is  soon  overdone 
and  there  is  a  return  of  some  of  the  symptoms.  Modified 
work  Avith  plenty  of  rest  is  frequently  helpful  when  the  more 
severe  symptoms  have  passed  away,  the  amount  of  work 
being  regulated  by  its  effect  on  the  body  weight,  sleep  and 
pulse  rate,  etc.  Another  point  which  it  is  necessary  to 
emphasise  is  that  as  nerve  exhaustion  and  shock  cases  are 
highly  hyper- sensitive  persons,  care  should  be  taken  not  to 
convey  to  a  patient  that  you  suspect  him  of  not  trying  to 
recover.  If  one  takes  the  trouble  to  examine  a  patient  properly, 
it  is  easy  enough  to  test  this,  and  until  this  has  been  done  and 
evidence  found,  such  suggestions  should  not  be  made. 

For  years  we  have  been  awaiting,  and  we  still  await,  the 
day  when  special  hospitals  will  be  founded  and  equipped  with 
all  that  is  necessary  for  the  treatment  of  neurasthenic  and 
fatigue  states.  Now  would  seem  to  be  the  time  to  make 
a  start,  as  the  numbers  requiring  treatment  are,  and  will 
continue  to  be,  very  large.  Such  a  hospital  or  sanatorium 
must  contain  baths  and  electrical  apparatus  of  various  kinds, 
and  gymnasia,  and  if  possible  some  workshops.  Physicians 
experienced  in  psycho -therapeutic  methods  should  be  in  attend- 
ance, and  masseurs  and  persons  capable  of  giving  breathing 
and  voice  exercises  will  be  required.  Also  in  connection 
with   the    hospital   there   should    be    a    number    of   houses 


NEUROSES  AND  PSYCHO- NEUROSES  311 

provided  with  workshops,  facilities  for  open-air  employment, 
etc.,  where  the  patients  should  be  drafted  when  they  are  well 
enough  to  begin  limited  work ;  but  these  houses  should  be 
under  the  supervision  of  the  physicians  of  the  hospital  as  far 
as  possible.  In  re-educating  the  nerve-exhausted  person  to 
work,  the  employment  given  must  be  so  modified  as  always  to 
be  well  within  the  patient's  power,  as  any  mental  or  physical 
fatigue  must  be  avoided,  otherwise  a  relapse  will  ensue.  Another 
important  point  is  to  give  the  patient  ample  time  to  convalesce ; 
short  periods  are  worse  than  useless  for  two  reasons  :  in  the  first 
place,  the  man  has  the  constant  strain  of  feehng  that  he  has 
got  to  get  well  against  time  ;  or  he  is  sent  away  too  soon  and 
before  his  recovery  is  estabhshed. 

The  problem  is  a  large  one,  but  it  will  have  to  be  faced, 
otherwise  the  country  will  have  left  on  its  hands  many  men 
who  under  proper  conditions  might  have  been  restored  to 
health ;  these  will  either  be  pensioned,  or  from  no  fault  of  their 
own  will  drift  and  become  chronic  invalids  with  no  capacity 
for  work,  unable  to  keep  themselves  or  their  dependents. 

For  further  details  the  reader  is  referred  to  the  chapters 
on  Traumatic  Neuroses  and  Nerve  Exhaustion  States.  This 
chapter  has  been  written  specially  to  summarise  the  symptoms 
commonly  found  in  men  suffering  from  shock  and  stress 
of  war. 


312  PSYCHOLOGICAL  ilEDICINE 


CHAPTEE  XIX 

IXSAMTY  AKD  PHYSICAL  DISEASES 

The  relation  of  mind  to  body  has  aheady  been  briefly  dis- 
cussed in  a  former  chapter.  It  has  been  observed  that  in  all 
bodily  disease  there  is  some  accompanj^ing  mental  distm'bance, 
some  alteration  in  the  mind  of  the  individual.  This  mental 
aspect  is  frequently  overlooked,  even  when  it  forms  a  prominent 
symptom  m  a  case.  Similarlj'-,  there  is  a  physical  side  to  all 
mental  disease.  These  two  groups  of  symptoms  are  present 
in  every  case,  and  it  is  for  the  physician  to  decide  which  is 
primary.  Further,  it  is  necessary  to  consider  the  relationship 
of  the  one  to  the  other — whether,  for  example,  the  mental 
disorder  influences  the  course  of  the  bodily  disease  or  vice 
versa.  Insanity,  in  relation  to  some  of  the  more  common 
forms  of  physical  disease,  will  now  be  considered. 

Phthisis  and  Insanity 

The  relationship  of  phthisis  to  insanity  is  very  close.  In 
one  family  will  be  found  some  insane  and  some  phthisical 
members.  A  tubercular  parent  may  beget  children  who 
later  become  insane.  When  the  two  diseases  are  associated 
in  the  same  individual,  it  is  necessary  to  consider  which 
appeared  first.  Phthisis  has  been  in  the  past,  and  is  even 
at  the  present  day,  one  of  the  commonest  causes  of  death 
in  our  large  asylums.  The  great  majority  of  these  patients 
develop  phthisis  in  the  institution — that  is  to  say,  the  tuber- 
cular disease  is  secondary  to  the  msanity.  Occasionally 
it  occurs  that  a  man  who  has  been  phthisical  for  some  time 
undergoes  a  gradual  mental  change  until  he  becomes  definitely 
insane. 

Much  discussion  has  taken  place  as  to  whether  there  is  a 


PHTHISIS  AND  INSANITY  313 

special  form  of  insanity  that  can  rightly  be  called  '  phthisical 
insanity.'  In  examining  this  question,  all  those  patients  who 
develop  tubercular  disease  after  the  appearance  of  mental 
disorder  may  be  excluded.  When  insanity  is  consecutive  to 
the  lung  disease  the  patient  is  usually  depressed  with  delu- 
sions of  suspicion  and  ideas  of  poisoning  ;  but  this  type  of 
mental  disorder  is  certainly  not  limited  to  phthisical  persons 
and  is  found  in  other  forms  of  insanity.  There  is  no  special 
tj^pe  of  mental  disorder  which  is  either  characteristic  or  patho- 
gnomonic of  phthisis,  but  the  insanity  is  frequently  coloured 
by  the  special  physical  symptoms  of  the  particular  case.  The 
exhaustion  psychoses  are  the  most  common  variety  met  with 
in  these  cases. 

Types  of  Mental  Diseases. — As  already  observed,  mild  de- 
pression with  ideas  of  persecution  and  suspicion  is  the  most 
common  form  of  insanity  ;  occasionally  profound  restlessness 
and  agitation  are  exhibited. 

Mental  Symptoms. — These  patients  are  usually  disagree- 
able, querulous,  and  quarrelsome.  They  are  frequently  mildly 
depressed  and  unable  to  occupy  themselves.  At  times  they 
are  very  abusive  and  complain  that  poison  is  mixed  with  their 
food.  Eefusal  of  food  is  common,  and  oesophageal  or  nasal 
feeding  may  become  necessary.  The  memory  is  fairly  good, 
but  the  power  of  attention  fails  and  sustained  concentration 
of  thought  becomes  impossible. 

Any  delusions  that  may  be  present  are  usually  the  ex- 
planation the  patient  gives  for  his  altered  feelings  and 
sensations.  At  times  definite  delusions  of  persecution 
develop,  but  with  the  advance  of  the  disease  in  the  lungs 
these  ideas  usually  become  less  marked.  Ideas  of  filth 
may  be  a  symptom,  and  when  they  are  present  the  patient 
usually  washes  many  times  a  day.  A  suicidal  tendency  is 
common.  Hallucinations  are  found  in  about  a  third  of  the 
eases.  Head  has  drawn  attention  to  hallucinations  being 
common  in  persons  suffering  from  visceral  disease.  He  finds 
that  visual  hallucinations  are  common  in  phthisical  patients., 
and  that  auditory  hallucinations  are  also  frequent,  but  that 
instead  of  taking  the  form  of  '  voices  '  they  take  that  of  bell- 
ringing  and  taps.  He  states  that  they  only  occur  in  asso- 
ciation with  pain  from  the  lung  tissue  itself ;   for  instance  the 


314  PSYCHOLOGICAL  MEDICINE 

pain  of  pleurisy  will  not  give  rise  to  hallucinations,  as  the  pain 
is  not  a  referred  or  reflected  pain.  AVhen  mental  disorder 
supervenes  the  patient  ceases  to  complain  about  any  physical 
discomforts  that  he  may  formerly  have  felt  as  a  result  of  his 
phthisis.  This  has  led  to  the  belief  that  insanity  is  beneficial 
to  phthisis,  but  this  is  not  the  fact.  In  reality  the  mental 
disorder  merely  masks  the  physical  symptoms,  which  are 
usually  progressive. 

Physical  Symptoms. — The  physical  symptoms  are  largely 
those  found  in  ordinary  cases  of  phthisis.  Insomnia  may  be  a 
trying  symptom. 

Course. — In  the  majority  of  cases  the  course  is  a  progressive 
one  ;  mentally,  the  patient  tends  to  become  partially  weak- 
minded,  but  it  is  of  interest  to  note  that,  when  the  physical 
disease  becomes  extensive  and  life  itself  is  threatened,  there  is 
not  uncommonly  a  decided  improvement  in  the  mental  con- 
dition of  the  patient.  Hsemoptysis  and  severe  diarrhcea 
may  be  the  cause  of  fatal  collapse.  Sudden  terminations 
are  common  in  spite  of  every  precaution,  and  fatal  syncope 
may  occur  in  a  patient  in  whom  phthisis  was  not  known  to 
be  very  far  advanced. 

Diagnosis. — The  diagnosis  of  consecutive  phthisis  is  by  no 
means  easy,  and  frequently  the  disease  is  very  advanced  before 
it  is  discovered.  A  rapid  loss  of  body  weight — especially  if 
accompanied  by  intermittent  fever — may  connote  the  onset 
of  tubercular  disease.  In  the  insane  the  difficulties  of  aus- 
cultation are  very  great ;  the  chest  may  be  examined  thoroughly 
and  yet  reveal  little  or  no  disease.  When  the  mental  disorder 
is  secondary  to  the  phthisis,  the  onset  of  the  former  is  usually 
insidious.  The  patient  becomes  morose  and  irritable ;  he 
refuses  to  occupy  himself,  and  may  from  time  to  time  give 
expression  to  some  delusion.  Persistent  refusal  of  food  may 
be  an  early  symptom. 

Prognosis. — The  prognosis  depends  largely  upon  the  extent 
of  the  lung  mischief.  As  a  general  rule  the  outlook  is  not 
hopeful.  Most  patients  die,  but  there  may  be  recovery  from 
the  insanity  during  the  last  few  weeks  of  life. 

Treatment. — When  a  physical  disease  is  associated  with  a 
mental  disorder,  the  treatment  should  be  chiefly  directed 
towards  the  relief  of  the  former. 


DIABETES  AND  INSANITY  315 


Diabetes  and  Insanity 


Glycosuria  is  rarely  found  in  the  insane,  but  it  is  common 
in  neurotic  families.  There  is  no  special  form  of  insanity 
that  can  be  rightly  called  Diabetic  Insanity.  The  usual 
history  of  the  class  of  case  to  which  this  term  is  sometimes 
applied  is  as  follows  :  The  patient  has  been  suffering  from 
sugar  in  the  urine  for  some  months,  but  more  recently  he  has 
been  slowly  altering  mentally.  He  has  become  extremely 
irritable  and  over-anxious  ;  he  is  constantly  complaining,  and 
is  inclined  to  misinterpret  the  physical  symptoms  of  his  diabetes. 
He  is  depressed,  usually  more  markedly  in  the  morning.  There 
is  a  tendency  to  suicide,  or  an  actual  attempt  at  self-destruc- 
tion, may  have  been  made.  In  more  advanced  cases  there  is 
profound  melancholia  of  the  hypochondriacal  type.  Food 
is  frequently  refused.  Not  uncommonly  when  the  patient 
becomes  definitely  insane  the  glycosuria  disappears,  but  only 
to  return  when  there  is  a  remission  in  the  mental  symptoms. 
Sugar  is  found  in  the  urine  of  a  small  percentage  of  general 
paralytics. 

Prognosis. — The  prognosis  is  fair  in  persons  over  forty- 
five  years  of  age,  but  with  younger  patients  the  outlook  is  by 
no  means  good. 

Treatment. — The  treatment  is  chiefly  directed  to  alleviating 
the  diabetes.  In  some  cases  where  there  is  extreme  emacia- 
tion, the  physician  should  not  hesitate  to  resort  to  forced 
feeding,  and  he  may,  for  the  time  being,  ignore  the  presence 
of  sugar  in  the  urine.  A  careful  daily  record  should  be  kept 
of  the  amount  of  sugar  passed  and  the  dietary  should  be 
largely  regulated  by  these  figures.  It  will  be  found  that  a 
liberal  diet  is  not  always  followed  by  an  increased  percentage 
of  sugar. 

Influenza  and  Insanity 

The  toxic  elements  of  influenza  seem  especially  prone  to 
affect  the  nervous  system.  Few  persons  pass  through  an 
attack  of  influenza  without  showing  some  mental  or  nervous 
symptoms.  The  most  common  condition  is  one  of  mild  depres- 
sion ;    there  is  a  sense  of  indefinable  misery,  of  disinclination 


316  PSYCHOLOGICAL  MEDICINE 

for  the  slightest  mental  effort ;  the  patient  feels  unfit  for  work, 
and  small  annoj^ances  irritate  him.  Some  persons  suffer 
from  nem'algia  and  headaches  for  a  few  weeks  after  influenza, 
others  become  sleepless,  and  unless  carefully  treated  this 
insomnia  may  terminate  in  a  serious  mental  break-down. 
Severe  nerve  exhaustion  may  also  follow  influenza. 

It  is  not  always  the  bad  forms  of  influenza  which  are  followed 
by  nervous  symptoms ;  profound  mental  disturbances  are 
often  seen  in  persons  who  have  apparently  had  quite  a  mild 
attack  of  the  disease.  It  is  those  persons  with  an  unstable 
heritage  who  are  especially  liable  to  be  affected.  Actual 
mental  disorder  may  appear  during  the  febrile  stage  of  the 
disease,  in  which  case  the  insanity  is  commonly  of  the  maniacal 
type.  Post-influenzal  insanity  is  more  usual,  and  the  mental 
disorder,  which  is  usually  of  the  melancholic  variety,  develops 
during  the  succeeding  weeks  or  months  after  the  illness.  The 
insanity,  in  both  cases,  is  usually  of  the  exhaustion  type,  and 
the  reader  is  referred  to  the  chapters  describing  this  condition. 

Mental  Ssmiptoms.— The  mental  symptoms  vary  with  the 
time  of  the  onset  of  the  insanity.  If  they  appear  during  the 
febrile  stage  the  symptoms  are  those  of  acute  mania.  The 
patient  becomes  noisy  and  restless,  and  hallucinations,  especially 
of  sight,  are  common.  The  excitement  may  be  very  intense 
and  may  necessitate  removal  to  an  asylum.  After  a  time  the 
maniacal  symptoms  may  abate,  and  the  patient  passes  into  a 
stuporose  or  depressed  condition.  Food  may  be  refused  at 
any  stage,  in  which  case  forced  feeding  must  be  resorted  to. 
If  the  mental  disturbance  is  post-febrile  in  onset,  it  may 
develop  within  a  few  days  or  weeks  from  the  cessation  of  the 
fever. 

The  onset  is  frequently  very  insidious  ;  the  insanity  may 
be  slowly  developing  for  weeks  or  months  before  it  is  even  sus- 
pected by  the  relatives  of  the  patient.  Weeks  of  sleeplessness 
may  gradually  undermine  the  nervous  energy  of  the  patient. 
The  body  weight  may  steadily  fall,  and  persistent  anorexia 
may  aggravate  the  condition.  Work  ]jecomes  a  labour,  the 
attention  fails,  and  indolence  and  apathy  become  marked. 
The  morning  hours  usually  bring  a  sense  of  misery,  and  suicidal 
feelings  slowly  assert  themselves.  If  improvement  does  not 
take    place    the   next   stage  is  one   of   profound   depression. 


INFLUENZA  AND  INSANITY  817 

Delusions  and  hallucinations  may  appear,  and  the  condition 
becomes  one  of  acute  melancholia.  Self-accusation  and  ideas 
of  unworthiness  are  frequent  in  some  persons  ;  others  become 
hypochondriacal.  The  physical  symptoms  are  similar  to  those 
found  in  acute  melancholia. 

Prognosis. — The  prognosis  is  good  if  treatment  is  undertaken 
in  the  ear]y  stages  of  the  insanity.  Some  cases  recover  within 
a  few  months.  Persistent  auditory  hallucinations  frequently 
point  to  chronicity,  and  when  they  are  present,  the  physician 
should  be  careful  not  to  give  too  favourable  a  prognosis. 

Treatment. — As  in  most  other  diseases,  the  treatment 
resolves  itself  into  two  kinds  :   (a)  prophylactic  ;  {h)  curative. 

(a)  Proijhylactic. — Influenza,  especially  when  it  occurs  in  a 
neurotic  subject,  requires  proper  treatment.  The  diet  shoald 
be  liberal  and  consist  of  nourishing  foods,  such  as  milk  and 
eggs.  Patients  will  frequently  complain  that  they  have  no 
appetite,  and  on  this  account  will  ask  to  be  excused  from 
eating  what  is  placed  before  them.  Such  persons  require 
very  firm  management.  To  give  way  to  their  wishes  is  to 
court  disaster.  The  body  weight  should  be  recorded  week  by 
week  ;  every  few  pounds  lost  means  a  stage  nearer  a  nervous 
collapse,  while  increased  body  weight  brings  increased  security. 
Insomnia  should  be  treated.  Eest  from  work  is  necessary, 
but  the  holiday  should  be  wisely  used  and  not  spent  in  travel- 
ling or  in  other  ways  conducive  to  the  production  of  physical 
exhaustion. 

(fe)  Curative. — The  curative  treatment  of  insanity  follow- 
ing or  associated  with  influenza  is  similar  to  that  already 
described  under  the  exhaustion  psychoses.  In  the  post-febrile 
insanities  it  is  often  difficult  to  decide  when  the  limits  of 
sanity  have  been  crossed  ;  it  is  probably  owing  to  this  difficulty 
that  so  many  persons  succeed  in  committing  suicide  before 
being  placed  under  care.  The  danger  of  snicide  is  a  very 
real  one,  and  the  physician  must  always  be  on  the  watch. 

Chorea  and  Insanity 

There  is  no  form  of  mental  disorder  that  can  properly  be 
called  Choreic  Insanity.  Every  patient  suffering  from  chorea 
usually  exhibits  some  symptoms  of  mental  disturbance.    Many 


318  PSYCHOLOGICAL  MEDICINE 

of  these  patients  are  dull  and  listless,  with  general  apathy  and 
loss  of  memory  ;  but  as  the  mental  symptoms  are  so  slight  in 
comparison  with  the  physical,  they  are  commonly  overlooked. 
More  rarely  the  mental  disorder  is  very  severe  and  calls  for 
immediate  treatment.  Sir  William  Gowers  has  shown  that 
chorea  is  more  likely  to  occur  in  neurotic  families  than  in  the 
more  stable  ones.  The  insanity  may  be  consecutive  to  the 
chorea,  or  vice  versa. 

etiology. — Mental  comphcations  during  an  attack  of 
chorea  are  more  commonly  seen  in  adults  than  in  children, 
and  they  usually  occur  in  very  unstable  persons.  Women 
who  develop  chorea  during  pregnancy  seem  especially  Hable 
to  mental  disorder  during  the  attack,  but  it  must  be  borne  in 
mind  that  chorea  seldom  occurs  in  the  adult  as  a  first  attack 
— usually  the  patient  has  suffered  from  a  previous  attack  in 
childhood. 

Mental  Symptoms.  —  In  consecutive  mental  disorder  the 
insanity  may  be  one  of  several  types,  (a)  Choreic  mania 
rarely  begins  before  the  end  of  the  first  week  of  the  outbreak 
of  the  chorea,  and  seldom  occurs  after  the  fourth  week.  At 
times  it  is  very  difficult  to  say  when  the  limits  of  sanity  have 
been  passed,  as  the  impulsiveness  and  loss  of  control  grow 
gradually  out  of  the  restless  agitation  so  commonly  seen  in 
patients  with  chorea.  Sleep  becomes  very  broken  until 
the  condition  is  one  of  complete  insomnia.  Consciousness 
becomes  clouded,  and  the  patient  may  fail  to  attend  to  the 
calls  of  nature.  Hallucinations  of  sight  and  hearing  may  be 
present. 

(6)  The  mental  state  may  be  one  of  depression,  with  the 
belief  that  recovery  is  impossible.  This  is  more  commonly 
met  Avith  in  pregnant  women. 

(c)  Acute  delirium  of  a  very  severe  type  may  develop. 
This  form  differs  from  the  ordinary  choreic  mania  chiefly  in 
the  severity  of  both  the  mental  and  somatic  symptoms.  This 
insanity  is  a  severe  exhaustion  psychosis.  The  following 
symptoms  are  usually  present  :  fever,  hallucinations  of  sight, 
restlessness,  excitement,  extreme  insomnia,  and  refusal  of 
food.  The  chief  danger  lies  in  prostration  and  exhaustion, 
which  may  terminate  fatally. 

(d)  The  general  confusion  and  mental  hebetude  so  commonly 


CHOREA  AND  INSANITY  319 

seen  in  choreic  patients  may  become  more  profound,  until  the 
condition  becomes  one  of  stupor  with  defects  in  memory. 

(e)  Delusions  of  persecution  may  develop  in  cases  of  chronic 
chorea. 

(/)  It  has  been  noticed  that  consecutive  chorea,  i.e.  chorea 
appearing  in  a  patient  who  is  insane,  is  nearly  always  chronic. 

(g)  Huntington's  chorea  (hereditary  progressive  chorea) 
was  described  by  Huntington  in  1872.  The  chief  character- 
istics of  this  disease  are  that  it  (1)  is  hereditary,  occurring 
in  certain  families  throughout  several  generations  ;  (2)  is  a 
disease  of  middle  life,  usually  between  the  ages  of  thirty  and 
forty-five  ;  (3)  affects  both  sexes  equally,  and  may  be  trans- 
mitted by  either  males  or  females  ;  (4)  is  a  progressive  and 
incurable  condition  ;  (5)  is  a  disease  which  is  accompanied  by 
mental  deterioration,  steadily  tending  towards  dementia. 
The  chronic  twitchings  at  first  appear  in  the  face  and  upper 
limbs  and  gradually  extend  to  all  the  voluntary  muscles  of 
the  body.  The  movements  at  first  are,  to  a  certain  extent, 
under  control,  and  in  this  way  differ  from  those  of  ordinary 
chorea  ;  for  example,  a  patient  can  easily  put  a  button  through 
a  buttonhole  or  perform  other  exact  movements.  Usually 
in  time  the  movements  become  more  extensive  and  less 
controllable.  The  twitchings  cease  during  sleep.  The  heart 
is  normal,  and  sensation  is  unaffected.  The  gait  is  charac- 
teristic, the  patient  sways  from  side  to  side,  and  moves  in 
a  spasmodic  way.  The  early  mental  changes  are  those  of 
general  apathy  and  indifference.  There  may  be  a  period  of 
great  depression,  which  is  at  times  broken  by  outbursts  of 
irritability  and  excitement.  Sooner  or  later,  the  mental  state 
passes  into  that  of  dementia,  which  may  become  profound. 
This  disease  does  not  tend  to  shorten  life. 

Physical  Symptoms.  —  The  general  health  usually  suffers 
severely  in  all  those  forms  of  chorea  where  there  are  consecu- 
tive mental  complications.  Huntington's  chorea  is  an  excep- 
tion. In  the  acute  delirious  forms  and  more  serious  types 
of  choreic  mania  the  physical  health  is  markedly  affected, 
and  there  are  disturbances  of  the  functions  of  all  organs. 
Nutrition  fails  and  there  is  a  general  wasting  of  tissue.  Ee- 
fusal  of  food,  which  is  a  common  symptom,  increases  the 
difficulty  of  maintaining  the  patient's  strength. 


320  PSYCHOLOGICAL  MEDICINE 

Course. — The  course  is  a  faiily  rapid  one  in  all  cases  in  which 
acute  mental  disorder  supervenes  on  an  attack  of  chorea,  and 
the  patient  either  dies  or  shows  signs  of  improvement  within  a 
few  weeks.  In  a  small  percentage  of  cases  the  improvement 
does  not  continue  and  chronic  mental  disorder  results.  This  ter- 
mination is  more  common  in  the  delusional  and  stuporose  types. 

Prognosis. — The  prognosis  is  usually  good  in  the  maniacal 
and  depressed  forms  of  mental  disorder  when  associated 
with  chorea.  With  acute  delirium  the  condition  is  more 
serious,  and  the  prognosis  in  the  fir'st  instance  should  be  of 
a  guarded  natm^.  Nevertheless,  when  the  patient  begins 
to  improve  there  is  seldom  a  relapse.  Huntington's  chorea 
is  progressive  and  incurable. 

Pathology  and  Morbid  Anatomy. — The  pathology  of  these 
conditions  is  very  obscure,  but  the  view  held  by  Sir  William 
Gowers,  that  the  disease  originates  in  the  motor  cells  of  the 
cortex,  has  much  evidence  in  its  favour.  Many  authorities 
believe  that  the  change  is  due  to  a  toxin.  In  persons  dying 
from  choreic  insanity  there  is  usually  found  at  post-mortem 
a  very  marked  hyper semia  of  the  brain.  In  the  chronic  forms 
of  chorea  there  is  a  progressive  degenerative  change  to  be 
observed  in  the  cells  of  the  motor  cortex. 

Treatment. — The  treatment  is  largely  symptomatic.  Food 
should  be  liberal  and  of  a  nomishing  nature  and  consist 
chiefly  of  milk,  eggs,  and  custards.  The  more  acute  the  attack, 
the  greater  must  be  the  amount  of  food  given.  Forced  feeding 
should  not  be  long  deferred  in  the  event  of  refusal  of  food. 
Stimulants  may  be  necessary  in  severe  cases.  Any  tendency 
to  constipation  should  be  corrected  ;  it  is  wise  to  keep  the 
bowels  freely  open.  Sedatives  must  be  given  if  sleep  is  not 
obtained  naturally,  the  form  of  hypnotic  used  largely  de- 
pending upon  the  age  and  general  condition  of  the  patient. 
Chloral  hydrate  is  the  best  to  use,  when  it  can  be  safely  em- 
ployed. If  the  patient  is  very  restless  or  inclined  to  be  violent, 
he  should  be  placed  upon  a  mattress  on  the  floor  and  surrounded 
by  other  mattresses  in  order  to  prevent  bruising. 

Insanity  of  Myxcedbma 

All  persons  suffering  from  myxoedema  exhibit  some  mental 
change,  but  it  varies  in  degree  in  different  cases.     In  some 


MYXCEDEMA  AND  INSANITY  321 

the  intellectual  disturbance  becomes  so  great  that  it  calls  for 
special  treatment,  while  in  others  it  is  barely  noticeable.  It 
is,  however,  always  necessary  to  remember  that  there  is  a 
mental  aspect  to  this  illness  ;  otherwise  the  prominence  of  the 
physical  symptoms  may  be  allowed  to  obscure  the  mental, 
with  the  result  that  some  unforeseen  accident  takes  place, 
which  greater  circumspection  might  have  avoided. 

iEtiology. — This  disease  is  brought  about  by  the  failure  of 
the  thyroid  gland  to  perform  its  normal  function.  It  usually 
appears  between  the  ages  of  thirty  and  fifty-five,  and  is  more 
common  in  women  than  in  men. 

Mental  Symptoms. — The  early  stage  of  myxcedema  is  usually 
marked  by  a  steady  deterioration  in  the  intellectual  powers  of 
the  patient.  Mentation  is  deliberate,  and  there  is  failure  of 
general  apprehension.  Movements  and  thoughts  are  slower. 
The  memory  is  defective  for  recent  events.  The  patient  may 
have  outbursts  of  irritability.  Work  which  was  formerly  per- 
formed with  ease  becomes  increasingly  difficult ;  mistakes  are 
frequently  made  and  the  daily  task  is  indifferently  discharged. 
Speech  is  slow  and  the  voice  monotonous,  and  there  is  in- 
ability to  grasp  written  or  spoken  words.  These  patients  are 
usually  fully  aware  of  their  slowness  in  thought  and  action 
and  frequently  complain  about  it,  in  fact  many  of  them  are 
acutely  conscious  of,  and  depressed  by,  the  failure  of  their 
intellectual  powers. 

If  the  patient  remains  untreated,  the  general  lethargy 
increases  and  there  is  marked  drowsiness.  He  becomes  too 
lazy  to  wash  or  dress  himself.  Movements  become  more  and 
more  sluggish  and  are  made  in  a  clumsy  fashion.  The  patient 
readily  fatigues  ;  he  is  indifferent  to  his  surroundings,  and 
he  pays  no  heed  to  the  wants  of  others.  The  emotional  aspect 
varies,  but  the  majority  of  these  patients  are  mildly  depressed 
with  vague  ill-defined  fears.  The  early  irritability  may 
develop  into  acute  excitement.  In  advanced  cases  there 
may  be  both  delusions  and  hallucinations,  and  at  times  there 
is  marked  exaltation. 

Physical  Symptoms. — The  physical  symptoms  of  myxoedema 
are  fully  described  in  text-books  on  medicine,  but  for  the 
convenience  of  the  student  the  more  important  ones  will  be 
briefly  referred  to  here.     The  skin  of  the  face  becomes  swollen 

21 


322  PSYCHOLOGICAL  MEDICINE 

and  waxy  in  appearance.  The  cedema  is  elastic,  but  does  not 
j)it  on  pressure  nor  alter  by  gravitation.  The  eyelids,  nose, 
and  lips  are  all  thickened.  The  skin  throughout  the  body  is 
similarly  affected,  and  it  is  rough  and  dry  to  the  touch.  Per- 
spiration is  defective  or  entirely  absent.  The  hair  and  nails 
are  brittle  and  readily  split  ;  the  former  comes  out,  often 
leaving  the  patient  quite  bald.  The  teeth  decay.  The  hands 
become  broad  and  '  spade-like,'  and  fine  movements  of  the 
fingers  are  impossible.  The  mucous  membraies  are  also 
involved,  and  the  tongue  is  large  and  thickened.  Areas  of 
exceptional  thickness  may  be  found  in  the  axillse  and 
supra-clavicular  regions,  and  the  abdomen  may  be  large 
and  pendulous.  The  temperature  of  the  body  is  usually  sub- 
normal ;  some  patients  complain  of  constant  chilliness  and 
readily  notice  all  thermal  changes.  The  pulse  frequency  is 
slower  than  normal.  Ansemia  is  well  marked  when  the  disease 
is  advanced,  and  there  is  a  tendency  to  haemorrhages  from 
the  mucous  surfaces.  The  bowels  are  usuaUy  constipated  ; 
there  may  be  amenorrhcea  in  the  female,  and  in  some  cases 
menstruation  is  excessive. 

Prognosis. — If  left  untreated  the  course  is  towards  mental 
and  physical  deterioration,  but  the  progress  may  be  slow 
and  even  broken  by  periods  of  apparent  return  to  health. 
Ultimately  death  results  from  coma  or  more  commonly  some 
intercurrent  disease.  \^Taen  placed  under  treatment  a  general 
improvement  is  quickly  observed  both  in  the  nutrition  of 
the  body  and  the  mental  processes.  If  the  treatment  has 
been  started  comparatively  early  in  the  com'se  of  the  disease, 
complete  recovery  may  be  expected  ;  but  where  the  illness  has 
extended  over  a  considerable  period  of  time,  the  damage  to  the 
nervous  system  may  be  too  serious  to  repair. 

Diagnosis. — The  diagnosis  ought  not  to  be  difficult.  The. 
gi-eatest  danger  of  overlooking  the  true  diagnosis  is  when  marked 
mental  symptoms  have  developed,  especiall}^  if  these  are  acute. 
It  is  a  common  error  merely  to  diagnose  insanity  and  never 
attempt  to  discover  the  cause  of  th(^  mental  distui'bance. 

Pathology  and  Morbid  Anatomy. — The  thyroid  gland  is 
atrophied  or  diseased.  Iodine  is  the  active  principle  of  the 
internal  secretion  of  the  thyroid  gland  and  the  name  of  thyro- 
iodine  has  been  given  to  it,  and  it  is  the  absence  of  this  body 


MYXCEDEMA  AND  INSANITY  323 

which  gives  rise  to  myxoedema.  In  the  early  stages  there 
is  a  small-celled  infiltration  of  the  walls  of  the  vesicles,  and 
later  the  gland  is  converted  into  fibrous  tissue,  throughout 
which  are  scattered  collections  of  epithelial  cells  and  colloid 
masses  which  are  the  remnants  of  the  former  vesicles.  The 
changes  in  the  skin  are  due  to  a  hyperplasia  of  the  connective 
tissue.  In  the  brain  the  neuroglia  may  be  found  to  be  greatly 
increased,  and  there  is  frequently  a  marked  overgrowth  of 
the  connective  tissue  round  the  vessels.  Some  observers 
have  noted  a  tumefaction  of  the  nerve-cells.  Examination 
of  the  blood  reveals  an  increase  of  the  white  corpuscles  and 
a  diminution  of  the  red. 

Treatment. — It  is  wise  to  begin  with  small  doses  of  thyroid 
and  gradually  increase  if  found  necessary.  This  method  has 
a  dual  advantage  in  that — (1)  the  smaller  doses  may  be 
sufficient  to  promote  recovery  ;  (2)  it  is  with  the  larger  doses 
that  untoward  results  are  apt  to  occui'.  Three  to  five  minims 
of  liquor  thyroidei  (B.P.),  or  three  grains  of  thyroideum  siccum 
(B.P.),  should  be  given  once  a  day.  At  first  it  is  better  to  keep 
the  patient  in  bed.  Morning  and  evening  temperatm-es  and 
the  frequency  of  the  pulse  should  be  recorded.  If  improve 
ment  does  not  take  place,  the  dose  should  be  gradually  in- 
creased. At  no  time  should  the  drug  be  pressed  with  the 
idea  of  getting  the  patient  better  as  rapidly  as  possible  ;  such 
a  com'se  is  fraught  with  no  small  risk.  The  following  symp- 
toms indicate  that  the  dose  must  be  reduced  :  persistent  frontal 
headache,  dizziness,  ii-regular  cardiac  action,  diarrhoea,  urticaria, 
fever,  emaciation,  trembling,  etc.  If  everything  is  satis- 
factory, both  mental  and  physical  improvement  quickly  takes 
place.  The  general  appearance  of  the  patient  alters,  and 
mentation  becomes  more  active  and  the  memory  retm'ns. 
Many  recover  within  three  months,  but  patients  must  be  made 
to  understand  that  it  will  be  necessary  to  continue  taking 
extract  of  thyroid  gland  during  the  remainder  of  their  lives. 
The  dose  can  usually  be  limited  to  small  dimensions  ;  each 
patient  varies  in  this  respect,  and  the  proper  amount  neces- 
sary to  keep  him  in  health  can  only  be  discovered  by  careful 
observation. 


324  PSYCHOLOGICAL  MEDICINE 

Exophthalmic  Goitre 

The  .prominent  symptoms  of  this  disease  are  palpitation 
of  the  heart  and  frequent  pulse,  protusion  of  the  eyeballs, 
tremors  and  mental  symptoms  associated  with  enlargement 
of  the  thyroid  gland.  Some  authorities  consider  that  it  is 
the  antithesis  of  myxoedema  and  that  it  is  produced  by  over- 
activity of  the  thyroid  gland,  but  this  is  not  accepted  by  all. 

etiology. — It  is  more  common  in  females  than  in  males 
and  usually  appears  between  the  ages  of  twenty  and  forty 
years.  A  neurotic  inheritance  can  as  a  rule  be  obtained.  The 
exciting  cause  may  be  worry  or  physical  and  mental  exhaustion. 

Mental  Symptoms. — There  is  marked  irritability  and  restless- 
ness. The  patient  has  periods  of  depression  accompanied  by 
dreads  and  fears  of  some  impending  harm.  Sleep  is  defective 
in  quality  and  quantity.  Sudden  flushings  of  the  head 
and  face  are  complained  of.  Sensation  may  be  unaltered, 
but  when  there  is  extreme  weakness  hallucinations  of  sight 
may  occur.  Memory  is  good,  but  the  power  of  attention  is 
lessened.  The  emotional  condition  at  times  becomes  one  of 
great  excitement  and  in  some  cases  delusions  of  persecution 
are  the  prominent  feature  of  the  mental  aspect  of  the  illness. 

Physical  Symptoms. — For  a  full  account  of  these  the 
reader  is  referred  to  a  text-book  of  medicine,  but  for  con- 
venience the  main  symptoms  will  be  tabulated  here.  The 
thyroid  in  some  cases  may  be  much  enlarged,  but  in  others 
such  enlargement  may  not  be  marked.  The  four  cardinal 
symptoms  are  prominence  of  the  eyeballs,  acceleration  of 
the  pulse,  enlargement  of  the  thyroid,  and  muscular  tremors. 
There  is  widening  of  the  palpebral  fissure  which  is  due  to  the 
retraction  of  the  upper  Ud  (Stellwag's  sign),  and  diminution 
of  bhnking.  In  downward  movements  of  the  eyes  the  upper 
lid  lags  behind  (von  Graefe's  sign).  The  tremors  may  affect  the 
whole  body,  and  they  are  very  marked  if  the  patient  becomes 
agitated.  There  may  be  a  diminished  expansion  of  the  chest 
during  inspiration  (Bryson's  symptom)  ;  dyspnoea  may  be 
severe.  A  yellowish  pigmentation  of  the  skin  may  be  observed. 
Anaemia,  muscular  weakness,  and  emaciation  occur  in  most 
cases.  The  appetite  may  be  excessive.  Diarrhoea  and  vomiting 
are  not  micommon.     The  patient  may  perspire  freely. 


EXOPHTHALMIC  GOITRE  AND  INSANITY  325 

Prognosis. — Many  cases  recover  with  treatment.  The  dura- 
tion of  the  illness  is  variable.  Some  cases  die  within  a 
few  months  ;  others  may  live  for  years  in  this  state  and 
finally  recover.  The  mortality  is  stated  to  he  about  twenty- 
five  per  cent.  The  outlook  is  more  grave  when  there  is  very 
great  mental  excitement  or  when  there  is  emaciation  with 
diarrhoea  and  vomiting.  Eapid  recovery  may  take  place  in 
some  cases,  but  the  outlook  is  always  very  uncertain.  Some 
patients  improve  when  operated  upon. 

Morbid  Anatomy  and  Pathology. — The  thyroid  is  enlarged 
and  there  is  an  increased  vascularity  of  the  gland.  The 
epithelium  lining  the  vesicles  is  changed  from  the  cubical 
to  the  columnar  type.  The  contents  of  the  alveoli  contain 
much  mucin  as  well  as  colloid  matter.  There  is  an  increase 
of  fat  in  the  orbit.  The  thymus  is  not  only  persistent  but 
in  some  cases  is  hypertrophied.  Kocher  lays  great  stress  on 
the  examination  of  the  blood  in  Graves'  disease.  There  is 
a  diminution  in  the  polynuclears  and  an  increase  of  the 
lymphocytes.  The  essential  cause  of  this  disease  is  still  a 
matter  of  uncertainty.  Over-activity  of  the  thyroid  gland  is 
held  to  be  the  cause  by  some  authorities  especially  in  persons 
whose  thymus  is  persistent. 

Treatment. — General  hygienic  rules  should  be  followed  as 
to  the  locality  for  treatment,  diet,  etc.  If  there  is  much 
emaciation  rest  in  bed  is  necessary.  Bloodgood  divides  the 
cases  into  three  groups  as  regards  treatment  :  (a)  Advanced 
cases  with  exaggerated  symptoms.  Surgical  treatment  is  often 
fatal  and  not  to  be  recommended  ;  X-rays  and  serum-therapy 
should  be  tried.  (&)  Well-marked  cases  without  very  acute 
symptoms.  The  results  here  with  operation  are  so  good 
that  it  is  doubtful  whether  delay  in  favour  of  medical  treat- 
ment is  permissible,  (c)  Mild  cases.  Medical  treatment  and 
X-rays  should  be  tried  and  will  cure  a  certain  number  of 
cases. 

Cretinism 

etiology. — Cretinism  occurs  in  certain  well-defined  areas 
and  is  closely  connected  with  goitre.  It  is  met  with  chiefly 
in  valleys  ;    and   in   certain    districts    most   of   the   children, 


326  PSYCHOLOGICAL  MEDICINE 

including  those  of  perfectly  healthy  parents,  become  cretins. 
Dr.  Ireland,  in  his  book  on  '  The  Mental  Affections  of  Children,' 
writes  :  '  It  would  appear  that  the  cause  which  produces  goitre 
alone  when  it  is  feeble,  produces  cretinism  when  it  acts  with 
greater  intensity.'  Domestic  animals  are  affected  with  goitre. 
If  children  are  moved  into  the  higher  districts  they  do  not 
develop  cretinism.  Evidence  tends  to  indicate  that  the  disease 
is  produced  by  the  drinking  water,  but  careful  search  has 
failed  to  eMcit  what  the  exact  deleterious  material  or  poison 
actually  is.  As  above  indicated,  cretinism  is  usually  endemic, 
but  sporadic  cases  occur  from  time  to  time,  either  as  the 
result  of  congenital  absence  of  the  thyroid  gland  or  from 
atrophy  or  other  changes  in  this  organ. 

Physical  Symptoms.— As  a  general  rule  cretinism  is  not 
recognised  until  the  child  is  about  two  or  three  years  of  age, 
but  a  certain  number  of  cases  show  symptoms  soon  after  birth. 
In  infancy  the  condition  can  be  recognised  by  the  eyehds 
appearing  heavy  and  swollen  ;  the  skin  is  of  a  yellow  colour 
and  the  tongue  is  large  and  flabby.  But  it  is  during  the  sub- 
sequent years  that  the  disease  becomes  more  recognisable. 
These  children  do  not  grow  like  other  children,  but  remain 
squat  and  diminutive,  and  some  are  dwarfs.  The  head  is 
flattened  at  the  top,  and  the  fontanelles  may  be  widely 
opened.  The  forehead  is  low  and  narrow.  The  nose  is  flattened. 
The  eyehds  have  a  solid  transparent  appearance  and  look 
oedematous,  but  there  is  no  pitting  on  pressure  ;  a  similar 
condition  is  to  be  observed  about  the  hands  and  feet  and 
various  other  parts  of  the  body.  The  thickening  about  the 
neck  is  very  noticeable,  and  frequently  a  firm  swelling  can  be 
seen  and  felt  on  either  side  of  the  neck.  The  thyroid  gland  as 
a  rule  cannot  be  felt.  The  lips  are  thick  and  the  tongue  swollen. 
Dentition  is  late  and  the  teeth  are  badly  formed.  Sahvation 
is  common.  The  limbs  are  large  but  very  feeble.  Walking 
is  not  acquired  until  the  child  is  three  or  four  years  of  age, 
and  in  some  cases  later  than  this.  The  gait  is  slow  and  clumsy. 
The  skin  is  coarse  and  thick  and  devoid  of  perspiration. 
Speech  is  very  late  in  developing  and  is  usually  confined  to 
a  few  badly  pronounced  words  ;  the  voice  is  harsh.  The 
abdomen  is  large  and  distended.  The  sexual  organs  develop 
late  and  imperfectly  or  remain  in  a  rudimentary  state.     Some 


CRETINISM  AND  INSANITY  327 

of  these  children  are  deaf  and  others  bhnd,  but  the  majority 
of  them  have  good  sight. 

Mental  Characteristics. — The  mental  symptoms  vary  from 
mild  confusion  and  general  apathy  to  a  condition  of  pro- 
found idiocy.  The  child  fails  to  develop  intellectually  and 
is  stupid  and  dull.  Thought  is  slow,  and  there  is  inability 
to  acquire  knowledge.  The  Sardinian  Commission  divided 
cretins  into  three  classes,  according  to  the  degree  of  their 
mental  capacity  : 

(a)  The  first  class  consisted  of  those  entirely  devoid  of  any 
intellectual  faculty,  without  power  of  speech  or  reproduction. 
These  were  named  simply  cretms. 

{h)  In  the  second  class  were  placed  those  whose  intellectual 
capacity  was  confined  to  satisfying  their  bodily  wants,  who 
could  speak  in  a  rudimentary  language,  and  who  could 
reproduce.     These  were  named  semi-cretins. 

(c)  In  the  third  class  were  comprised  those  who  possessed 
all  the  faculties  of  those  in  the  second  class,  but  had  greater 
intellectual  powers,  and  who  with  careful  training  could  acquire 
the  knowledge  of  a  trade.  These  were  named  cretineux  or 
cretinous. 

Course. — The  course  of  the  disease  if  untreated  is  a  progres- 
sive one,  and  the  child  becomes  more  and  more  weak-minded 
and  the  body  remains  dwarfed.  Eickets  is  a  common  com- 
plication, and  in  a  certain  proportion  of  cases  severe  con- 
vulsive seizures  develop.  Death  is  generally  due  to  some  inter- 
current condition,  such  as  bronchitis,  convulsions,  or  diarrhoea. 
Phthisis  is  in  rare  cases  associated  with  cretinism. 

Prognosis. — The  prognosis  is  not  so  good  as  might  be  expected 
from  the  possibility  of  moving  the  child  from  the  district  in 
which  the  disease  is  rife  to  more  healthy  surroundings,  and 
from  the  advantages  of  treatment  with  thyroid  gland. 
Physical  improvement  may  take  place  without  any  mental 
improvement. 

Pathology  and  Morbid  Anatomy. — The  morbid  anatomy  is 
by  no  means  certain,  and  the  changes  found  in  the  brain  are 
very  varied.  The  bones  of  the  skull  are  sometimes  abnormally 
tliick,  but  occasionally  thinned  ;  Wormian  bones  between  the 
sutures  are  common.  Virchow  believed  that  a  characteristic  con- 
dition of  the  skull  of  the  cretin  was  premature  ossification  of  the 


328  PSYCHOLOGICAL  MEiOICINfi 

S2)heno-basilar  bone,  serving  to  prevent  the  elongation  of  the 
base  of  the  skull  and  so  to  limit  the  development  of  the  brain. 
Lombroso  and  other  observers  agree  with  Virchow  that  the 
distance  from  the  root  of  the  nose  to  the  occipital  foramen 
is  shortened  in  cretins,  but  find  that  there  are  many  cases 
which  do  not  show  an  early  ossification  of  the  spheno-basilar 
suture.  The  brain  is  usually  asymmetrical.  The  convolutions 
are  unusually  simple  in  arrangement.  In  some  instances 
there  is  dilatation  of  the  ventricles  and  the  brain  is  atrophied. 
In  the  majority  of  cases  of  cretinism  there  is  some  disease  of 
the  thyroid  gland. 

Treatment. — The  treatment  has  been  divided  into  the 
jDrophylactic  and  curative  methods.  Dr.  Baillarger  suggests 
the  following  important  points  in  dealing  with  the  endemic 
type  of  the  disease  :  (a)  to  combat  the  general  causes  of  in- 
salubrity, to  improve  the  hj'^gienic  conditions,  and  increase 
the  well-being  of  the  population  exposed  ;  (b)  to  change  the 
drinking  water ;  (c)  to  institute  everywhere  a  gratuitous 
com'se  of  treatment,  which  should  at  once  begin  upon  the 
appearance  of  goitre  or  cretinism.  When  possible  the  children 
should  be  moved  from  the  valleys  into  the  mountainous  dis- 
tricts. The  diet  should  consist  largely  of  good  milk.  The 
children  should  be  carefully  clothed,  as  they  feel  the  slightest 
changes  of  temperature.  According  to  recent  observations  it 
has  been  found  that  the  early  administration  of  thyroid  is 
sometimes  very  useful  in  preventing  the  progress  of  the  disease, 
but  it  is  rare  to  get  much  mental  improvement.  Thyroid 
must  be  taken  for  the  rest  of  the  patient's  life.  In  some  cases 
iodide  of  potassium  given  in  small  doses  gives  good  results. 

Gout  and  Insanity 

There  are  nearly  always  some  mental  changes  during  or 
preceding  an  attack  of  gout.  These  alterations  may  be  slight 
or  severe,  and  they  consist  of  the  following :  morning  depression, 
great  irritability,  failure  of  attention  and  of  power  of  appli- 
cation, and  at  times  sensory  and  motor  disturbances.  An 
attack  of  gout  may  be  accompanied  by  sleeplessness,  a  symptom 
which  usually  aggravates  the  condition.  Gout  and  insanity 
may   alternate.     A   man  suffering  from   acute  podagra   may 


GOUT  AND  INSANITY  329 

suddenly  develop  insanity,  and  when  this  takes  place  the  gout 
usually  disappears,  but  only  to  return  when  the  mental  dis- 
turbance is  past.  Before  this  alternation  was  recognised, 
medical  men  were  blamed  for  '  driving  the  gout  in  '  by  the 
treatment  adopted.  It  is  now  known  that  this  metastasis  may 
take  place  apart  from  any  active  treatment.  Any  disease  which 
alters  the  blood  and  so  affects  the  nutrition  of  the  brain 
may  tend  to  produce  insanity.  In  gout  the  blood  is  vitiated, 
and  this  must  lead  to  changes  in  the  various  nervous  centres. 

Mental  Symptoms. — The  mental  symptoms  are  usually 
those  common  to  melancholia.  Suicidal  feelings  are  often 
prominent.  Auditory  and  visual  hallucinations  may  develop. 
There  is  great  insomnia,  and  the  patient  may  be  very  restless. 
At  times  an  outbreak  of  acute  excitement  may  occur. 

Physical  Symptoms. — When  an  attack  of  insanity  super- 
venes, the  joint  troubles  frequently  disappear,  and  the  physical 
symptoms  are  those  common  to  melancholia.  As  the  patient 
recovers,  one  or  more  joints  may  become  inflamed,  but  with 
rest  and  care  they  soon  get  well. 

Diagnosis. — In  many  cases  reliance  has  to  be  placed  to  a 
gi'eat  extent  upon  the  history  given  by  the  patient  or  his 
friends  and  the  presence  of  such  symptoms  as  tophi  in  the 
ears.  Where  the  joints  are  still  affected,  the  diagnosis  is 
easy.     An  examination  of  the  blood  may  also  assist. 

Prognosis. — The  prognosis  in  the  majority  of  cases  is  dis- 
tinctly good,  and  many  patients  recover  within  a  few  months. 
The  outlook  is  bad  in  patients  suffering  from  acute  delirious 
symptoms. 

Treatment. — The  treatment  is  prophylactic  or  curative. 
The  former  consists  of  regulating  the  patient's  mode  of  living 
both  as  regards  diet  and  exercise.  Care  should  be  exercised 
against  using  powerful  drugs  too  freely ;  they  sometimes 
aggravate  rather  than  alleviate  the  condition.  The  curative 
treatment  is  directed  towards  improving  the  state  of  the 
blood  and  in  this  way  the  general  nutritional  condition  of 
the  body.  The  bowels  require  careful  attention.  The  writer 
has  found  the  use  of  saline  purges  very  valuable.  Hot  air 
and  other  baths  are  very  beneficial  in  some  cases.  If  the 
patient  is  suicidal,  he  must  be  kept  constantly  under  super- 
vision, and  asylum  treatment  may  become  necessary. 


330  PSYCHOLOGICAL  MEDICINE 

Eheumatic  Fevee  and  Insanity 

Eheumatic  fever,  in  common  with  many  other  diseases, 
seems  to  be  in  some  way  closely  connected  with  mental  dis- 
order. It  nvaj  alternate  with  insanity  in  the  same  way  as 
gout,  diabetes,  and  other  maladies.  At  the  time  when 
large  doses  of  iron  were  given  in  the  treatment  of  rheu- 
matic fever,  if  insanity  supervened  the  medicine  was  not 
infrequently  blamed  for  producing  the  mental  disorder.  But 
the  same  thing  has  happened  when  sodium  salicylate  has  been 
employed,  and  clearly  it  is  not  the  drug  but  some  peculiarity 
in  the  disease  which  leads  to  changes  in  the  nerve-cells  of 
the  brain.  Apart  from  actual  insanity,  it  has  been  noticed  that 
after  an  attack  of  rheumatic  fever  the  patient  may  be  altered 
morally  or  intellectually.  On  this  subject  Savage  writes  :  ^ 
'  We  have  met  -^dth  several  patients,  mostly  women,  who  have 
ceased  to  perform  their  domestic  duties,  and  have  caused 
family  discord  in  consequence  of  their  changed  habits,  the 
industrious  mother  becoming  indolent  and  neghgent  of  her 
duties.  It  is  certain,  too,  that  some  persons  who  before 
rheumatic  fever  were  sober  and  truthful,  after  it  become 
intemperate  and  untruthful.' 

The  mental  disorder  may  appear  either  during  the  febrile 
stage  of  the  disease  or  during  convalescence.  The  dehrium  of 
the  fever  may  pass  on  to  acute  mania,  or  mental  disturbances 
may  gradually  develop  towards  the  end  of  the  illness.  In 
this  latter  case  the  insaility  may  take  the  form  of  mania  or 
melancholia,  but  excitement  is  more  common.  If  the  heart 
becomes  implicated,  the  mental  disorder  varies  to  some  extent 
according  to  the  valves  which  are  affected.  Mania  is  more 
common  vnth  aortic  disease,  and  melanchoha  ^^dth  mitral 
disease. 

Prognosis.- -The  prognosis  is  good,  and  most  cases  recover, 
but  there  is  a  danger  of  recurrence  with  any  subsequent  attack 
of  rlieumatic  fever. 

Treatment. — The    treatment   is   on    general   lines,   but   the 

possibility   of  the  presence  of   cardiac   disease  must  not   be 

forgotten,  especially  if  the  patient  is  very  resistive  or  requires 

forced  feeding. 

^  '  Rheumatic  Feyer  and  Insanity,"  Tiike's  Diet,  of  PsychologicalMedicine. 


HEART  DISEASE  AND  INSANITY  331 

Heart  Disease  and  Insanity 

There  is  no  definite  relationship  between  heart  disease 
and  insanity  ;  but  in  that  the  brain  is  dependent  upon  the 
heart  for  receiving  a  regular  and  proper  supply  of  blood  for 
its  nourishment,  it  will  be  easily  understood  that  valvular 
obstruction  or  incompetence  may  be  a  factor  in  the  production 
of  mental  disorder.  Anxiety  and  restlessness  are  common 
symptoms  in  aortic  insufficiency,  and  other  mild  forms  of 
mental  aberration  may  be  observed  in  patients  with  cardiac 
disease.  Sleeplessness  is  another  distressing  symptom  in 
some  cases  of  heart  disease  and  one  that  is  prone  to  lead 
to  insanity  in  neurotic  subjects.  Persons  with  aortic  incom- 
petence who  develop  mental  disorder,-" usually  suffer  from 
acute  mania  or  one  of  the  exhaustion  psychoses,  whilst  those 
with  early  mitral  disease  are,  as  a  rule,  depressed.  This 
is  what  we  should  expect  to  find,  as  the  former  have  a  low 
blood-pressure,  and  the  latter  a  high  one.  When  discussing 
phthisis  and  mental  disorder  we  reminded  the  reader  of  Head's 
observations  on  referred  pam  m  association  with  disease  of 
the  viscera.  The  same  remarks  regarding  hallucinations  and 
mental  depression  are  applicable  when  the  patient  is  suffering 
from  aortic  regurgitation,  aneurism,  combined  aortic  and 
mitral  disease  and  in  adherent  pericardium,  provided  there 
is  pain  associated  with  any  one  of  these  diseases. 

Sunstroke  and  Insanity 

Great  heat  or  exposure  to  a  burning  sun  may  be  the  deter- 
mining stress  w^hich  brings  on  a  convulsive  seizure  in  one 
whose  brain  is  degenerating  from  early  dementia  paralytica, 
but  to  say  that  sunstroke  was  the  cause  of  his  ultimately 
exhibiting  symptoms  of  general  paralysis  is  not  true.  Again, 
a  man  on  the  verge  of  syphihtic  insanity  may  be  overcome 
by  heat  on  a  summer  day  or  even  have  a  '  seizure,'  but  in 
this  case  the  effect  of  the  sun  has  only  been  to  exaggerate 
an  already  existing  disease.  Prolonged  exposure  to  the  sun, 
living  in  a  tropical  climate,  or  even  a  period  of  exceptional 
heat  in  a  countiy  such  as  England,  may  produce  chronic  nerve 
exhaustion  or  determine  an  attack  of  acute  hallucinatory 
insanity  in  predisposed  persons. 


332  PSYCHOLOGICAL  MEDICINE 

Malaria  and  Insanity 

Mental  disorder  may  arise  in  connection  with  malaria  in 
the  same  way  as  it  does  in  other  fevers  due  to  specific  toxins. 
During  the  febrile  stage  there  may  be  acute  delirium  with 
sleeplessness,  and  this  may  develop  into  a  more  permanent 
form  of  insanity.  In  other  cases  the  mental  disorder  may  be 
intermittent  and  apparently  replace  the  febrile  stage.  This  is 
said  to  occur  most  commonly  with  the  quartan  variety,  and 
rarely  with  the  tertian  and  quotidian.  The  condition  is  one 
of  intense  excitement  accompanied  by  hallucinations,  chiefly  of 
the  auditory  and  visual  types.  Upon  treatment  with  quinine 
recovery  usually  takes  place.  Some  patients  after  an  attack 
of  malaria  suffer  a  great  deal  from  neuralgia  and  insomnia, 
and  marked  sj^mptoms  of  mental  disorder  may  subsequently 
develop. 

Syphilis  and  Insanity 

The  study  of  the  relationship  of  syphilis  to  mental  disease 
is  a  very  important  one  to  the  State,  and  of  intense  interest 
to  the  physician. 

Various  authorities  express  widely  different  views  as  to  the 
part  syphilis  plays  in  producing  mental  disorder.  Because 
a  man  has  had  syphilis  and  he  subsequently  becomes  insane, 
it  by  no  means  follows  that  the  insanity  is  related  to  or  caused 
by  the  syphilis. 

True  syphilitic  disease  of  the  nervous  system  has  very 
characteristic  symptoms,  and  unless  these  are  present  there  is 
no  proof  that  the  malady  in  question  is  of  syphilitic  origin. 
There  are,  however,  cases  of  insanity  in  which  there  is  little 
or  no  doubt  as  to  the  true  origin  of  the  disease  being  syphilitic, 
or  at  least  to  the  relationship  between  the  two  conditions  being 
more  than  an  accidental  one.  Constitutional  syphilis  may 
give  rise  to  a  cachectic  condition  by  the  direct  action  of  the 
poison  on  the  blood,  or  it  may  lead  to  arterial  disease,  or  it 
may  j^roduce  local  or  diffuse  disease  of  the  brain  and  its 
coverings,  or  scattered  gummata.  There  are  not  sufficient 
data  to  prove  that  mild  attacks  of  syphilis  are  more  apt  to  be 
followed  by  nervous  disorders,  and  there  is  much  evidence  to 


SYPHILIS  AND  INSANITY  333 

the  contrary.  Syphilis,  Hke  many  other  diseases,  does  not 
affect  all  persons  in  a  similar  way  ;  in  one  man  it  is  the  viscera 
which  suffer  most,  and  in  another  the  vascular  or  nervous 
system. 

Savage  ^  has  drawn  up  the  following  scheme  of  the  relation- 
ship between  syphilis  and  insanity  : 

(a)  Insane  dread  of  syphilis. 

(b)  Insane  dread  of  results  of  syphilis. 

(c)  Syphilitic  fever,  delirium,  and  mania. 
{d)  Acute  syphilis,  leading  to  mental  decay. 

(e)  Syphilitic  cachexia  and  dyscrasia,  and  mental  dis- 
order. 

(/)  Syphilitic  neuritis  (optic),  suspicion,  mania. 

(g)  Syphilitic  ulceration,  disfigurement,  and  morbid  self- 
consciousness. 

{h)  Congenital  syphilis,  cranial,  sensory,  and  nerve-tissue 
defects. 

(i)  Congenital  syphilis,  epilepsy,  idiocy. 

{k)  Infantile  syphilis  acquired. 

{T)  Constitutional  syphilis  :  (1)  vascular  or  fibrous ;  (2) 
epilepsy  ;  (3)  hemiplegia  ;  (4)  local  palsies  ;  (5)  general  para- 
lysis, spinal  (spastic  and  tabetic),  peripheral. 

(m)  Locomotor  ataxy  :  (1)  with  insane  crises  ;  (2)  with 
insane  interpretation  of  the  ordinary  symptoms. 

The  first  class  comprises  those  psychasthenic  persons  who 
are  suffering  from  a  morbid  fear  of  syphilis  ;  this  is  in  reality 
an  obsession  and  the  term  '  syphilophobia  '  has  been  used  to 
denote  it.  The  patient  is  always  washing  and  is  scrupulously 
clean  in  all  he  does  and  cleanses  the  various  utensils  out  of 
which  he  eats  his  food.  This  dread  may  lead  to  marked 
depression.  These  persons  misinterpret  any  spots  or  marks 
about  their  bodies  into  symptoms  of  syphilitic  disease. 
They  may  become  intensely  suicidal. 

The  second  class  of  patients  are  in  many  ways  similar  to 
the  true  syphilophobic  cases  in  their  conduct,  as  they  are 
most  particular  in  cleansing  everything  they  use.  They 
are  more  likely  to  be  suicidal,  and  this  symptom  should  be 
carefully  watched.  A  man  may  believe  that  he  has  given 
syphilis  to  his  wife  and  child,  and  acute  remorse  and  depression 
1  •  Syphilis  and  Insanity,'  Tuke's  Diet,  of  Psychological  Medicine. 


334  PSYCHOLOGICAL  MEDICINE 

may  result.  To  send  such  a  man  travelling  is  dangerous 
in  the  extreme  and  usually  ends  in  disaster.  It  is  far  wiser 
to  treat  him  as  an  acute  melancholiac  and  potential  suicide. 
Syphilitic  fever  has  been  known  to  be  followed  by  an  attack 
of  acute  mania.  Probably  the  patient  has  been  worrying 
about  his  illness  and  sleeping  badly  ;  and  when  the  secondary 
symptoms  appear  he  becomes  feverish,  and  later  delirious,  and 
this  temporary  excitement  is  followed  by  more  lasting  mania. 
The  condition  is  a  very  curable  one,  and  the  insanity  rarely 
lasts  more  than  two  or  three  months. 

Syphilis  may  have  a  serious  effect  on  the  general  health 
of  the  patient.  Now,  it  must  be  borne  in  mind  that  anything 
which  seriously  interferes  with  the  nutrition  of  the  body 
tends  to  produce  mental  disorder.  This  is  noticeably  the 
case  in  predisposed  and  neurotic  subjects.  The  careless 
administration  of  mercury  seems  to  assist  in  undermining  the 
physical  health  and  in  producing  a  cachectic  condition,  which 
ultimately  leads  to  trophic  changes  in  the  braiu  and  subsequent 
insanity.  The  symptoms  may  be  those  of  a  rapid  dementia, 
or  the  condition  rather  that  of  sub-acute  melancholia  or 
acute  mania.  When  syphilis  attacks  the  face  or  some  other 
exposed  sm-face,  the  patient  may  become  hypersensitive  to 
the  gaze  of  those  about  him.  He  may  beheve  that  everyone 
notices  that  he  has  syphilis,  and  may  suspect  that  they  shun 
him  or  talk  about  him.  In  time  he  may  slowly  weave  a 
definite  scheme  of  persecution  and  pass  into  a  chronic 
delusional  state. 

Congenital  syphilis  may  lead  to  defects  in  the'  nervous 
system,  which  may  result  in  failure  of  the  development  of  the 
mental  faculties,  or  convulsive  seizures  and  subsequent  inter- 
ferences with  mental  evolution  ;  or  it  may  cause  blindness 
or  deafness,  and  thus  deprived  of  one  or  more  special  senses, 
the  child  may  remain  feeble-minded.  This  question  is  again 
dealt  with  in  the  chapter  on  Idiocy  and  Imbecility.  Constitu- 
tional syphihs  is  specially  prone  to  attack  the  blood-vessels 
and  the  connective  tissue  of  the  nervous  system.  The  nerve- 
cells  and  theii'  processes  are  affected  in  a  secondary  way  by 
pressm-e,  which  at  first  leads  to  alteration  of  functions  and 
later  to  atrophy  and  degeneration. 

Syphilis  is  one  of  the  most  important  factors  in  the  produc- 


SYPHILIS  AND  INSANITY  335 

tion  of  sclerosis  of  the  arteries  and  what  has  been  written  on 
arteriopathic  insanity  is  appHcable  here.  Usually  the  patient 
is  over  fifty  ;  he  becomes  irritable  and  suspicious  with  loss  of 
■.memory.  He  may  have  exaggerated  ideas  regarding  himself  ; 
but,  unHke  the  usual  general  paralytic,  he  is  conscious  of  his 
failing  memory  and  mental  enfeeblement.  He  may  develop 
various  forms  of  coarse  paralyses.  Lumbar  puncture  shows 
no  lymphocytosis.  Mott  in  making  a  differential  diagnosis 
between  syphilitic  and  parasyphilitic  affections  writes  : — 

'  The  average  time  between  syphilitic  infection  and  onset 
of  symptoms  is  ten  years  in  parasyphilitic  affections  ;  very 
seldom  is  it  under  five  years,  whereas  the  converse  is  the  case 
with  syphilitic  affections.  In  the  severe  forms  of  syphilitic 
disease  of  the  central  nervous  system  the  greatest  number  of 
cases  occur  in  the  first  few  years  after  infection  and  diminish 
with  each  succeeding  year.  Whereas  the  syphilitic  history  is 
well  defined  and  the  scars  of  lesions  are  common  in  syphilitic 
disease,  they  are  comparatively  rare  in  the  parasyphilitic  affec- 
tions. The  onset  of  symptoms  and  course  of  syphilitic  disease 
are  usually  rapid  and  subject  to  regressions  and  remissions  ; 
the  onset  of  symptoms  and  the  course  of  parasyphilitic 
affections  are  usually  insidious  and  slowly  progressive,  except 
in  some  cases  of  general  paralysis,  especially  those  in  which 
there  are  numerous  seizures,  causing,  it  may  be,  transitory 
aphasias,  monoplegias,  and  hemiplegias.  The  pupil  and  squint 
phenomena  are  common  in  syphilis,  but  Argyll  Kobertson 
pupil  extremely  rare.  In  parasyphilis,  pupil  phenomena  and 
strabismus  are  common,  Argyll  Eobertson  pupil  is  rarely 
absent,  especially  in  tabes  and  tabo-paralysis.  Optic  neuritis 
and  post-neuritic  atrophy  are  not  uncommon  m  syphilis.  A 
unilateral  central  scotoma,  the  other  eye  remaining  healthy 
(an  indication  of  a  retrobulbar  neuritis)  affecting  the  papillo- 
macular  bundle,  is  indicative  of  a  gummatous  meningitis.  In 
parasyphilis,  primary  optic  atrophy  occm-s  in  about  ten  per 
cent,  of  the  cases.  Bladder  disturbances  are  common  in  syphilis 
and  parasyphilis.  Severe  headache,  worse  at  night,  stiffness 
of  the  neck,  coarse  paralysis  of  cranial  nerves,  paralysis  of 
limb  and  face  with  clonus  and  plantar  extensor  response,  are 
common  as  a  result  of  syphilitic  brain  disease,  but  rarely  if 
ever  met  with  m  general  paralysis.     Aphasisas,  anarthria,  and 


336  PSYCHOLOGICAL  MEDICINE 

dj'sarthiia  are  common  in  brain  sj-philis,  but  not  in  general 
paralysis,  in  which  the  speech  affection  is  characteristic.  In 
fact  the  term  '  general  paresis  '  is  much  more  correct  for  the 
parasyphilitic  brain  affection.  The  knee-jerks  in  a  gummatous 
meningitis  maj  be  present  one  day,  absent  the  next;  in  tabes 
they  are,  in  the  great  majority  of  cases,  absent  throughout. 
The  knee-jerks  are  exaggerated  in  the  great  majority  of  cases 
of  general  paralysis,  but  there  is  no  ankle  clonus  or  Babinski — 
in  fact  these  signs,  in  a  case  of  dementia,  to  my  mind  indicate 
strongly  syphilitic  brain  disease  rather  than  general  paralysis.' 

Diagnosis. — The  diagnosis  is  largely  dependent  on  the  past 
history  of  the  patient  or  the  marks  of  former  syphilis.  Exam- 
ination of  the  cerebro-spinal  fluid  and  of  the  blood  by  the 
Wassermann  test  should  always  be  made.  Scattered  lesions 
are  very  significant,  especially  if  they  clear  up  under  anti- 
syphihtic  treatment.  Brain-syphilis  may  be  very  intermittent, 
the  patient  rapidly  progressing  towards  recovery  and  then 
relapsing,  and  later  again  improving. 

Prognosis. — The  prognosis  varies  according  to  whether  the 
mental  change  is  functional  or  produced  by  organic  disease. 
Those  patients  who  suffer  from  morbid  dreads  or  hypersensi- 
tivity usually  recover  if  the  treatment  is  started  early  enough. 
When  the  insanity  is  the  result  of  disease  in  the  brain  and 
its  coverings,  or  in  the  cerebral  blood-vessels,  the  outlook  is 
by  no  means  favourable.  About  one-fourth  of  these  cases 
recover,  but  there  is  a  hability  to  relapse  at  some  subsequent 
date.  The  most  hopeful  cases  are  those  which  present  signs 
of  local  gummata,  whereas  in  those  which  are  the  result  of  a 
slow  vascular  change  the  prognosis  is  decidedh^  bad.  In  all 
cases  early  treatment  will  give  the  best  results. 

Pathology  and  Morbid  Anatomy. — ]\Iott  ^  states  that  sypliilis 
may  operate  in  two  ways  as  a  factor  in  the  production  of 
insanity.  '  Firstly,  the  poison  may  produce  a  specific  in- 
flammatory process  affecting  the  membranes  and  blood- 
vessels of  the  central  nervous  system,  either  of  which  may  be 
affected  separately  or  together.  The  process  may  be  local  or 
general.  The  inflammatory  process  may  produce  direct 
irritation  or  destruction  of  the  nervous  elements,  the  blood- 

1  '  Relation  of  Syphilis  to  Organic  Brain  Disease,'  Archives  of  Neurology, 
1899,  vol  i. 


SYPHILIS  AND  INSANITY  337 

vessels  may  be  partly  or  completely  occluded,  and  the  effects 
on  f mictions  will  depend  on  the  extent  of  the  process.  The 
inflammatory  process  may  also  give  rise  to  neoplastic  growths, 
which  may  undergo  regressive  metamorphosis  in  the  older  parts 
(gummata),  but  all  the  processes  are  pathologically  identical, 
and  it  may  be  observed  that  though  there  is  really  no  absolute 
specific  character  about  them,  yet  experience  has  taught  us 
that  the  lesions  are  pathognomonic  of  syphilis.  Secondlj^ 
syphilis,  whether  acquired  or  inherited,  may  lower  the  specific 
vital  energy  of  the  component  cells  of  the  body  as  a  whole,  or 
the  cells  of  particular  tissues  or  organs.' 

Ford  Eobertson  ^  writes  :  '  In  the  insanity  of  tertiary 
syphilis  the  functional  disturbance  in  the  cortical  nerve-cells 
is  chiefly  secondary  to  narrowing  and  occlusion  of  cerebral 
arteries  by  endarteritis  obliterans,  and  to  the  mechanical 
and  other  effects  of  gummatous  and  meningitic  lesions.'  In 
the  brains  of  three  cases  of  syphilitic  insanity  which  this 
observer  examined,  he  found  '  shght  but  distinct  infiltration 
of  the  adventitia  of  the  arterioles  with  round  cells  ;  that  is  to 
say,  an  acute  periarteritis  similar  to  that  found  in  advanced 
j)aralysis.  In  each  case  there  was  also  to  be  observed,  scattered 
throughout  the  cortex,  a  few  hyaline  capillaries  presenting 
the  same  features  as  the  thickened  capillaries  so  characteristic 
of  general  paralysis.  The  neuroglia  changes  were  slight, 
consisting  in  a  moderate  degree  of  hyperplasia  in  the  first 
layer  in  all  three  cases,  and  of  similar  conditions  in  the  white 
matter  of  one.  ...  It  is  further  to  be  remarked  that  in  some 
cases  of  vascular  syphilitic  insanity  the  inflammatory  change 
in  the  intima  is  exceedingly  acute,  and  the  new  formation  of 
tissue  very  rapid.  In  others  this  morbid  process  is  com- 
paratively very  slow.  In  most  cases  of  general  paralysis  it 
may  be  observed  that  there  is  a  slight  new  formation  of  tissue 
in  the  intima  of  the  large  cerebral  arteries  and  pial  and  intra- 
cerebral arterioles.  The  cerebral  vascular  lesions  in  these  two 
diseases  would  therefore  appear  to  form  a  continuous  series. 
On  these  and  other  grounds  I  am  strongly  inclined  to  beheve 
that  the  vascular  forms  of  syphilitic  insanity  and  general 
paralysis  of  syphilitic  origin  are  pathologically  very 
closely  related  to  each  other,  and  that  they  blend  at  their 

1  Pathology  of  Mental  Disease. 

22 


3B8  PSYCHOLOGICAL  MEDICINE 

confines.  Both  are  determined  by  a  toxic  cond'tion,  which 
develops  as  a  result  of  previous  syphilitic  infection ;  the 
differences  in  the  site  and  intensity  of  the  vascular  changes 
may  depend  upon  certain  special  characters  of  the  toxsemia 
or  merely  upon  the  individual  reaction.' 

The  vessels  Avhich  are  most  commonly  affected  by  a  cellular 
prohferation  of  the  endarterium  are  the  vessels  belonging  to 
the  circle  of  Willis,  the  arteries  of  the  Sylvian  fossa,  and  the 
lenticulo-striate  arterioles.  In  some  cases  the  dm*a  mater 
and  pia-arachnoid  are  much  thickened  and  the  latter  is  ad- 
herent to  the  convolutions.  The  gyri  are  at  times  atrophied, 
and  the  lining  membranes  of  the  ventricles  are  granular.  The 
spinal  cord  and  its  arteries  may  also  show  syphilitic  changes, 
and  gummata  or  cicatrices  may  be  observed  in  the  liver  and 
other  organs.  Congenital  syphilitic  disease  of  the  brain  may 
result  from  specific  endarteritis,  or  chronic  meningitis,  or  it 
may  be  primary  and  independent  of  these  conditions.  Accord- 
ing to  Barlow  and  Bury,  the  most  common  brain-lesion  met 
with  in  hereditary  syphilis  is  a  cortical  sclerosis  which,  micro- 
scopically examined,  shows  atrophy  of  cells  and  overgrowth 
of  neurogha  tissue. 

Treatment. — The  treatment  should  be  started  as  soon  as 
possible.  Some  physicians  prefer  to  give  iodide  of  potassium 
alone  ;  others  give  'it  in  conjunction  with  mercury.  The 
iodide  can  usually  be  pressed  with  advantage,  as  most  patients 
will  have  less  discomfort  from  the  larger  doses  than  when 
the  smaller  are  administered.  It  is  wise  to  begin  with  a  dose 
of  twenty  grains  three  times  a  day  and  increase  steadily 
until  each  draught  contains  fifty  or  sixty  grains.  Some 
observers  state  that  the  iodide  of  sodium  is  more  valuable 
than  the  potassium  salt  when  the  vascular  system  is  the  part 
\nost  affected,  as  potassium  iodide  has  a  tendency  to  increase 
arterial  tension.  The  mercury  is  usually  applied  in  the  form 
of  ointment  to  different  parts  of  the  body  or  limbs.  At  times 
it  is  better  to  give  the  iodide  and  mercury  alternately, 
a  course  of  one  for  a  month,  followed  by  a  few  weeks' 
administration  of  the  other.  If  the  headache  is  very  severe, 
the  patient's  head  should  be  shaved,  and  mercurial  ointment 
rubbed  into  the  scalp.  Salvarsan  gives  good  results  in  some 
cases. 


SYPHILIS  AND  INSANITY  339 

The  general  health  should  be  carefully  attended  to  ;  the 
teeth  must  be  cleansed  after  each  meal  and  a  mouth  wash  of 
chlorate  of  potash  used.  The  patient  must  be  kept  warm,  and 
all  food-stuffs  which  are  likely  to  produce  a  free  action  of  the 
bowels  should  be  avoided.  The  patient  must  be  kept  under 
stringent  treatment  for  several  months  and  must  be  told  that 
it  is  absolutely  necessary  for  him  to  live  in  the  future  a  strictly 
sober  and  regulated  life  :  quiet  work  and  liberal  holidays,  no 
alcohol,  and  no  excesses  of  any  kind.  Further,  it  will  be  wise 
for  him  each  year  to  have  a  course  of  antisyphilitic  treatment. 


840  PSYCHOLOGICAL  MEDICINE 


CHAPTEE  XX 

DEFECTIVE  MENTAL  DEVELOPMENT  :     IDIOCY  AND 
IMBECILITY,    MORAL  IMBECILITY 

Idiocy  and  Imbecility 

Most  of  the  forms  of  mental  disorder  which  have  been  con- 
sidered in  former  chapters  have  been  caused  by  a  process 
of  dissolution.  The  mental  capacity  of  the  individual  has 
slowly  degenerated,  and  step  by  step  attributes  which  have 
been  acquired  in  early  life  have  become  lost,  or  have  been 
held  in  abeyance  for  the  time  being.  The  conditions  are  very 
different  with  idiocy  and  imbecility,  for  here  there  is  failure  of 
evolution  and  defect  in  mental  development.  Some  children 
are  without  even  the  rudiments  of  mind.  They  possess  bodily 
organs  which  perform  their  functions  more  or  less  satisfac- 
torily, but  their  mental  power  is  a  negligible  quantity  ;  for 
they  see,  yet  do  not  perceive  ;  they  hear,  yet  do  not  understand. 

Idiocy  and  imbecility  differ  only  in  denoting  the  degree  of 
mental  enfeeblement.  The  idiot  is  marked  by  a  gi'eater 
degree  of  weak-mindedness  than  the  imbecile  and  is  in- 
capable of  learning  ;  the  imbecile  can  be  made  to  under- 
stand and  can  receive  rudimentary  education.  There  is 
another  class  of  the  mentally  deficient  usually  spoken  of 
as  the  '  feeble-minded,'  but  the  intellectual  development 
of  these  is  on  a  higher  level  than  that  of  the  imbecile.  Thus 
there  is  an  ascending  scale  of  mental  growth  beginning  at 
idiocy,  which  in  reahty  is  a  condition  of  amentia,  the  lowest 
type  of  idiot  being  devoid  of  all  attributes  which  go  to  form 
mind  ;  the  next  condition  is  that  of  imheciliiy,  where  we 
reach  the  threshold  of  rudimentary  intellect  and  find 
a  capacity  to  acquire  knowledge  in  its  humblest  forms.  A 
further  step  brings  us  to  the  feeble-minded,  in  whose  mental 
organisation  there  are  defects,  and  serious  defects,  covering 
a  wide  range,  but  whose  capacity  to  acquire  knowledge  and 


IDIOCY  AND  IMBECILITY  341 

to  benefit  by  education  is  larger  than  that  possessed  by  the 
imbecile.  With  the  '  feeble-minded  '  the  failure  may  merely 
be  shown  in  an  inability  to  learn  the  obligation  of  conformity 
to  the  moral  code  laid  down  by  society,  or  slowness  in  acquiring 
general  knowledge. 

etiology. — The  aetiology  of  idiocy  and  imbecility  is  in 
many  ways  similar  to  that  of  mental  disease  in  general,  but  it 
presents  some  special  features.  The  causes  can  be  grouped 
under  two  main  heads  :  (1)  Pre-natal ;  (2)  Post-natal.  A 
neurotic  inkeritance  will  be  found  to  exist  in  a  very  large  per- 
centage of  cases.  The  most  common  factors  are  insanity, 
epilepsy,  alcoholism,  and  syphilis  in  one  or  both  of  the 
parents.  Further,  an  imbecile  may  beget  an  imbecile  child. 
Ireland,  in  his  book  on  '  The  Mental  Affections  of  Children,' 
records  many  such  cases.  He  quotes  Halles,  in  his  '  Elementa 
Physiologica,'  as  saying  that  '  he  knew  of  two  noble- wo  men 
who  got  husbands  on  account  of  their  fortunes,  notwithstanding 
that  they  were  almost  idiots,  and  that  their  mental  defect 
had  spread  for  a  century  through  several  families,  so  that 
some  of  their  descendants  are  idiots  in  the  fourth  and  even 
in  the  fifth  generation.' 

Phthisis  or  other  wasting  diseases  in  the  parents  may  act 
as  determining  factors  in  the  production  of  idiocy  in  their 
offspring.  Syphilis  which  has  been  contracted  by  the  parent 
many  years  before  the  birth  of  the  child  is  not  very  prone  to 
produce  imbecility  in  the  latter  ;  but  syphilis  in  the  mother  at 
the  time  of  gestation  is  serious.  Since  the  Wasserm'ann  test 
for  syphilis  has  become  available  in  clinical  medicine  the 
number  of  idiots  whose  mental  enfeeblement  is  found  to  be 
due  to  syphilis  has  greatly  increased.  In  all  cases  of  idiocy  it 
is  important  now  to  test  the  blood  of  the  child  ;  for  if  syphilis 
is  discovered,  early  treatment  may  lead  to  rapid  improvement 
in  the  mental  state  of  the  patient. 

Alcoholism  in  the  parent  is  no  doubt  a  potent  factor  in  the 
production  of  idiocy.  Some  authorities  consider  that  too 
much  stress  has  been  laid  on  alcoholism  in  the  parent  as  a 
cause  of  idiocy  or  imbecility  in  the  offspring,  but  this  view 
cannot  altogether  be  accepted,  and  even  though  statistics 
may  not  give  a  very  high  rate  of  actual  idiocy  or  imbecility, 
nevertheless  when  the  number  of  children  exhibiting  less  marked 


342  PSYCHOLOGICAL  MEDICINE 

forms  of  degenerac}^  is  included,  the  percentage  of  the  mentally 
enfeebled  progeny  of  alcoholics  becomes  most  formidable. 
Further,  it  must  be  remembered  that  intemperance — and  this 
term  is  here  used  in  its  broadest  sense — ^lowers  the  resistance 
of  the  organism  and  thus  enables  other  stresses  to  act  with 
greater  force. 

The  children  of  a  consanguine  marriage  are  not  necessarily 
defective  in  mental  development.  The  subject  has  been  dealt 
with  elsewhere  and  need  not  be  again  referred  to.  The 
progeny  of  very  youthful  or  aged  parents  frequently  show 
mental  and  physical  deterioration. 

The  next  group  of  causes  are  those  which  arise  during 
gestation.  Fright,  shock,  and  accident  to  the  mother  when 
pregnant  are  frequently  stated  to  be  followed  by  the  birth  of 
a  weak-minded  child.  It  is  always  necessary  to  receive  with 
great  caution  causes  assigned  by  the  laity  ;  nevertheless  there 
is  little  doubt  that  severe  shock  to  the  mother  may  in  cer- 
tain cases  in  some  mysterious  way  affect  the  foetus  in  utero. 
Further,  this  may  occur  in  a  mother  whose  nervous  system 
is  stable  ;  though  clearly  the  result  of  shock  will  be  more 
marked  if  she  be  a  neurotic  subject.  Diseases  contracted  by 
the  mother  during  pregnancy  may  lead  to  idiocy  in  the  infant  ; 
no  matter  of  surprise  when  it  is  realised  how  close  is  the  inter- 
action of  the  circulation  of  the  mother  and  child,  and  how 
profound  must  be  the  effect  of  vitiation  in  the  mother's  blood 
on  the  nutrition  of  the  child. 

The  next  group  of  causes  are  those  which  operate  at  the 
time  of  birth.  Prolonged  labour  leading  to  protracted  pressure 
on  the  cranium  is  a  very  important  factor  in  the  production 
of  idiocy  and  imbecihty,  especially  among  first-born  children. 
There  are  many  more  male  than  female  idiots,  a  fact  which 
probably  accurately  reflects  the  high  percentage  of  cases  in 
which  there  is  a  history  of  protracted  labour,  male  infants  being 
not  uncommonly  larger  than  female.  A  history  of  aspliyxia  neo- 
natorum is  said  by  Langdon-Down  to  be  obtained  in  twenty 
per  cent,  of  all  cases  of  idiocy.  Injuries  hij  instruments  account 
for  a  small  number  of  cases. 

The  j)Osi-natal  causes  are  numerous,  but  the  following  are 
the  most  important.  Infantile  convulsions,  from  whatever 
cause,  account  for  a  large    number  of  idiots  and  imbeciles. 


IDIOCY  AND  IMBECILITY  343 

Seizures  not  only  damage  and  bring  about  a  deterioration  in 
the  nervous  elements,  but  they  greatly  interfere  with  further 
development,  and  the  child  remains  weak-minded.  Gross 
disease  of,  or  injuries  to,  the  brain  or  its  coverings  are  respon- 
sible for  a  small  percentage  of  the  feeble-minded  ;  while  the 
influence  of  specific  fevers,  such  as  scarlet  fever,  diphtheria, 
small-pox,  measles,  and  whooping  cough,  is  more  serious. 

In  conclusion,  defective  mental  development  in  some 
children  is  largely  due  to  bad  training  and  ill-regulated  edu- 
cation. As  with  so  many  other  abnormal  conditions,  the 
factors  which  tend  to  produce  idiocy  and  imbecility  are  not 
uncommonly  complex  ;  it  is  usually  incorrect  to  say  definitely 
that  the  condition  is  due  to  any  one  stress,  for  it  is  far  more 
frequently  the  result  of  a  combination  of  evils.  Take  for 
example  infantile  convulsions ;  these  may  originate  from 
some  peripheral  irritation,  such  as  teething  ;  still  this  stress 
acts  with  greater  force  upon  the  unstable  than  the  stable. 
Imbecility  may  arise  from  anything  that  may  interfere  with 
normal  evolution  in  the  infant  or  young  child,  for  with 
evolution  we  ought  to  get  increasing  complexity  of  the  nervous 
elements,  and  the  inter-connections  between  the  nervous 
centres  should  become  more  numerous.  It  is  in  these  that 
the  idiot  brain  is  found  to  be  deficient,  for  not  only  is  the 
brain  more  simple  in  arrangement,  but  most  of  the  association 
fibres  are  undeveloped.  Care  must  be  taken  not  to  confound 
cause  with  effect.  Premature  ossification  of  the  sutures  of 
the  skull  was  at  one  time  considered  to  be  a  cause  of  idiocy, 
but  this  view  is  not  accepted  at  the  present  day,  as  obser- 
vation has  shown  that  it  is  the  failure  on  the  part  of  the  brain 
to  develop  that  permits  of  the  early  ossification. 

Mental  Phenomena. — The  mental  phenomena  are  not  the 
same  in  all  varieties  of  idiocy  and  imbecility,  but  as  it  will  be 
more  simple  for  the  student  to  study  the  mental  symptoms  as 
a  whole,  a  general  symptomatology  will  first  be  considered, 
and  later,  when  the  different  types  of  idiocy  are  described,  the 
special  symptoms  of  each  type  will  be  tabulated.  It  is  im- 
possible in  a  book  of  this  size  to  enter  into  any  great  detail,  for 
it  must  be  borne  in  mind  that  the  question  of  defective  mental 
development  is  a  large  and  important  one,  and  for  its  proper 
review  a  whole  volume  would  be  required.     The  object  here 


344  PSYCHOLOGICAL  MEDICINE 

is  to  present  a  short  review  of  the  subject,  and  for  more  minute 
information  the  reader  must  turn  to  special  works  on  idiocy. 
It  has  already  been  pointed  out  that  the  mental  defects  of 
idiots  and  imbeciles  vary  in  degree  ;  at  the  lower  end  of  the 
scale  there  is  the  idiot,  whose  mind  is  almost  a  blank  and 
who  is  totally  incapable  of  learning,  while  at  the  other  end  is 
found  the  feeble-minded  individual,  who  has  not  only,  acquired 
an  elementary  knowledge,  but  may  even  be  an  adept  at  carving 
or  some  other  form  of  mechanical  occupation.  Between  these 
two  extremes  there  are  innumerable  degrees. 

The  sjnnptoms  will  be  found  to  be  partly  negative  and 
partly  positive  ;  in  other  words,  there  will  be  certain  mental 
attributes  missing  owing  to  failure  of  development  of  the 
higher  centres,  and  these  give  negative  results  ;  but  further, 
there  will  be  certain  abnormal  mental  symptoms  present,  pro- 
duced by  the  over-action  of  lower  centres  which  are  not 
controlled  as  they  should  be,  owing  to  the  imperfections  in  the 
higher  levels. 

Memory. — The  power  of  recall  in  idiocy  and  imbecility 
varies  greatly,  but  frequently  there  is  some  deficiency  even 
in  the  most  intellectual  of  the  feeble-minded.  They  have 
difificulty  in  forming  associates,  and  unless  ideas  are  associated 
the  memory  is  apt  to  be  faulty.  Inattention  also  interferes 
with  a  sound  memory,  and  most  idiots  are  readily  distracted. 
In  some  of  the  feeble-minded  the  power  of  recall  may  be 
extraordinarily  great,  but  the  possession  of  such  a  memory  is 
usually  of  little  value  to  its  owner,  as  it  is  generally  highl}^ 
specialised  and  seems  to  be  developed  at  the  expense  of  all 
other  faculties.  The  child  may  be  a  prodigy  at  figures  or  a 
genius  at  music,  but  totally  unable  to  remember  matters 
necessary  for  the  ordinary  conduct  of  life.  Language  may 
never  be  acquired,  and  when  it  is  rememl^ered  how  important 
word-ideas  are  to  memory — for  it  is  by  these  tokens  that  final- 
ity is  placed  on  all  incidents  and  thoughts — it  will  be  understood 
that  their  absence  in  the  mental  equipment  of  an  individual 
must  seriously  cripple  his  power  of  recall. 

Attention. — The  faculty  of  attention  is  an  attribute  of  late 
development  in  the  normal  child  ;  in  the  feeble-minded, 
mental  evolution  usually  stops  ])ofore  io  is  fully  acquired. 
Passive  or  spontaneous  attention  is  attention  in  its  humblest 


IDIOCY  AND  IMBECILITY  345 

form,  and  it  is  upon  this  that  we  largely  rely  as  a  safeguard 
against  sudden  dangers.  Even  this  type  of  attention  is  absent 
in  some  idiots,  and  in  consequence  their  powers  of  self-pre- 
servation are  limited.  Inattention  may  be  due  to  weakness 
of  the  stimuli  which  reach  the  brain,  and  this  condition  may 
arise  from  some  defect  in  the  special  sense-organ  itself  or  in 
afferent  fibres  leading  to  it.  Those  idiots  who  have  no  power 
of  voluntary  attention  are  uneducable  ;  the  greater  the  faculty 
of  attention  the  easier  is  the  training.  In  some  cases  the 
stimulation  of  one  sense-organ  is  not  sufficient  to  attract  the 
attention  ;  but  if  the  stimuli  are  such  that  they  are  capable 
of  acting  upon  two  or  more  of  the  senses  at  once,  interest  may 
be  aroused.  This  is  found  to  be  especially  the  case  when  the 
visual  sense  is  olie  of  the  senses  acted  upon. 

Sensation  and  Perception. — Sensation  is  defective  in  a 
large  percentage  of  idiots  and  imbeciles.  The  threshold  of 
minimal  intensity  seems  to  be  deeper  than  in  the  normal  subject, 
and  in  consequence  the  stimulus  must  be  greater  before  it 
produces  a  reaction. 

Sight. — About  eight  per  cent,  of  idiots  are  born  blind,  and 
many  become  so  within  the  first  few  years  of  life.  Apart  from 
actual  blindness,  many  others  have  serious  defects  in  their 
visual  apparatus,  such  as  myopia,  hypermetropia,  astigmatism, 
cataract,  strabismus,  nystagmus,  and  Daltonism. 

Hearing. — Hearing  may  be  defective  in  all  types  of  feeble- 
mindedness, but  care  must  be  taken  to  distinguish  between 
partial  deafness  and  inattention.  Deafness  may  be  the  cause 
of  mutism,  and  in  combination  they  greatly  interfere  with 
education.  The  deprivation  of  one  sense,  or  even  two — 
though  the  latter  is  clearly  a  more  serious  condition — does 
not  necessarily  lead  to  weak-mindedness  ;  nevertheless,  the 
lack  of  a  special  sense,  such  as  sight  or  hearing,  frequently 
connotes  idiocy,  for  that  which  has  given  rise  to  the  one  may 
also  produce  the  other. 

Tactile  Sensation. — There  is  usually  some  diminution  of 
tactile  sensibility,  and  in  some  cases  this  is  very  marked. 
The  idiot  handles  things  in  a  clumsy  way  and  often 
drops  them.  The  feeble-minded  frequently  exhibit  diminished 
sensibility  to  heat  and  cold.  Pain  is  not  so  acutely  felt, 
neither  does  it  appear  so  early  as  in  a  normal  individual. 


346  PSYCHOLOGICAL  MEDICINE 

Occasionally  the  tactile  sense  is  found  to  be  developed  to  a 
high  degree  of  perfection. 

Taste. — Perversions  of  taste  are  common,  and  the  idiot 
wiU  frequently,  if  permitted,  eat  revolting  matter.  Even  the 
higher  types  of  feeble-minded  persons  commonly  show  diffi- 
culty in  distinguishing  between  salt,  sweet,  bitter,  and  sour 
articles. 

Smell. — Smell,  like  all  other  special  senses,  is  usually 
imperfect,  but  in  a  few  isolated  cases  it  will  be  found  to  be 
abnormally  acute. 

Organic  Sensations.  —  The  organic  sensations  are  usually 
feebly  developed. 

It  is  not  always  clear  in  a  given  case  whether  the  defect 
is  greater  in  the  senses  or  in  the  perceptive  powers,  and  in  all ' 
probabiUty  the  latter  are  usually  at  least  as  much  at  fault  as 
the  former.  Quahtative  perception,  such  as  colour,  may 
be  present,  but  the  space  and  time  perceptions  are  usually 
lacking.  The  normal  child  soon  learns,  through  its  tactile 
and  visual  senses,  the  position  of  things  in  space,  but  this 
faculty  as  a  rule  is  very  defective  in  the  feeble-minded. 
Similarly,  temporal  perceptions  are  wanting,  and  many  im- 
beciles have  no  idea  of  duration.  The  general  diminution  of 
special-sense  sensibility  and  inability  to  perceive  is  one  of  the 
chief  difficulties  in  the  training  of  idiots  and  imbeciles  ;  and 
further,  it  largely  accounts  for  the  failm-e  of  then:  mental  de- 
velopment, for  it  is  by  sensations  that  knowledge  m  the  first 
place  is  acquired. 

Emotions  and  Sentiments. — Pleasure  and  displeasm-e  are 
not  exhibited  in  the  lower  grades  of  idiocy,  and  it  is  only  in  the 
highest  types  of  feeble-minded  that  they  are  found  to  be 
developed  in  any  great  degree.  A  strong  stimulus  may  pro- 
duce a  reaction  either  of  pleasure  or  pain,  but  the  description 
of  some  accident  or  the  breaking  of  bad  news  seldom  affects 
them.  The  idiot  responds  merely  to  physical  pain,  and  not 
to  moral.  Many  imbeciles  laugh  in  an  automatic  way,  but 
it  is  the  laughter  of  a  vacant  mind.  They  may  take  violent 
likes  and  dislikes,  but  these  may  only  be  temporary  ;  the 
enemy  of  to-day  may  be  the  friend  of  to-morrow.  The  aesthetic 
sentiment  is  not  usually  much  developed,  and  even  when 
present  it  is  of  a  perverted   kind.     Tlie  idiot  will  clap  his 


IDIOCY  AND  IMBECILITY  347 

hands  when  he  hears  music,  but  it  is  the  sound  and  rhythm 
that  please  him  rather  than  the  melody  and  composition,  and 
he  would  probably  be  equally  pleased  with  the  beating  of  a 
drum. 

The  religious  sentiment  is  usually  lacking  ;  with  the  idiot 
there  is  no  thought  beyond  the  present.  Truth  is  not  a  strong 
point  with  the  feeble-minded  ;  they  do  not  hesitate  to  lie  when 
they  wish  to  protect  themselves  against  accusation.  With  the 
average  idiot,  right  and  wrong,  truth  and  falsehood,  are  all 
ahke  ;  he  draws  no  distinction  between  meum  and  tuum. 
Altruism  is  not  a  vii'tue  met  with  among  imbeciles  ;  they 
recognise  but  one  person,  and  that  is  self.  They  may  be 
boastful,  with  an  exaggerated  idea  of  their  own  importance, 
and  are  frequently  irritable  and  intolerant  of  any  interference. 
The  feeble-minded  are  usually  inquisitive,  and  even  in  the 
lower  grades  curiosity  may  be  a  prominent  feature.  An  idiot 
is  indifferent  to  his  general  appearance,  but  in  the  higher 
types  of  imbecility  there  may  be  vanity  and  extravagance  in 
dress. 

Morals. — The  moral  sense  is  never  highly  developed  in 
the  feeble-minded,  and  it  may  be  entirely  absent.  They 
have  Uttle  sense  of  honom',  and  are  inclined  to  gratify  the 
desires  of  the  moment  'irrespective  of  the  consequences  in- 
cm-red.  They  readUy  become  the  dupes  of  unprincipled 
persons,  as  their  pride  is  easily  flattered.  In  some  of  the 
higher  classes  of  feeble-minded  individuals  it  may  be  in  the 
moral  sense  that  the  mental  deficiency  is  most  conspicuous. 
Such  persons  are  often  grossly  dissipated,  and  all  the  lower 
instincts  seem  to  run  riot,  as  there  is  no  inhibitory  control 
to  regulate  them.  Idiots  may  exhibit  great  cruelty  towards 
animals  and  be  brutal  in  their  treatment  of  children  and 
feeble  persons.  They  may  be  very  passionate  and  reckless. 
On  the  other  hand,  many  idiots  are  quite  docile  and  soon 
learn  the  things  which  please  or  displease  those  who  have 
authority  over  them. 

Personality. — The  lower  class  of  idiot  has  probably  no 
personaUty.  Any  thoughts  that  he  has  centre  round  the  most 
humble  of  organic  sensations,  such  as  hunger  and  thirst  ; 
even  those  in  the  next  gi'ade  higher  in  the  intellectual  scale 
usually  speak  of  themselves  in  the  thn-d  person.     The  '  ego  ' 


348  PSYCHOLOGICAL  MEDICINE 

is  composed  of  the  sum-total  of  all  sensations  and  ideas  at 
any  given  moment,  together  with  the  standard  ideas  of  self 
which  have  been  derived  from  the  social,  moral,  and  other 
self-concepts.  Kinsesthetic  sensation  plays  an  important  part 
in  the  building  up  of  the  idea  of  self,  and  if  this  sense  is 
deficient,  the  self-concept  must  be  inaccurate,  for  the  very 
data  upon  which  it  is  formed  are  faulty. 

Occupations. — The  lowest  class  of  idiot  is  quite  unteachable, 
and  he  never  occupies  himself  mth  any  kind  of  useful  em- 
ployment. He  is  fi-equently  destructive,  not  necessarily  with 
a  pm'pose  of  destroying,  but  rather  as  a  means  of  passing 
time.  The  idiot  whose  tendencies  are  vicious  will  destroy 
for  the  pleasm^e  it  gives  him  to  do  damage. 

The  next  class  are  those  who  are  late  in  learning  simple 
occupations,  and  who  never  get  beyond  elementary  attain- 
ments. The  higher  types  may  exhibit  great  aptitude  in 
learning  special  kmds  of  work.  Music  seems  to  appeal  with 
peculiar  force  to  the  feeble-minded  and  many  of  them  acquire 
some  knowledge  of  the  subject.  Mechanical  occupations  may 
be  quickly  learned  and  some  imbeciles  show  skill  far  above 
that  of  the  average  normal  person  in  wood-carving  and  similar 
pursuits.  In  isolated  instances  the  talent  exhibited  amounts 
to  genius.  Many  of  the  '  mathematical  wonders  '  are  indivi- 
duals who  belong  to  the  class  of  the  feeble-minded  ;  neverthe- 
less, they  are  capable  of  performing  great  feats  of  mental 
arithmetic.  Mimicry  is  a  common  pastime  with  imbeciles, 
and  some  of  them  are  very  gifted  in  their  power  of  imitating 
others,  and  advantage  is  taken  of  this  instinct  in  training 
them.  The  great  difficulty  in  teaching  the  feeble-minded  is 
their  inal)ility  to  concentrate  their  attention  ;  they  are  readily 
distracted  and  theii-  mind  wanders  from  subject  to  subject.  On 
the  other  hand,  if  once  they  have  learnt  to  do  some  craft  they 
usually  prove  to  be  excellent  workmen,  as  they  pursue  their 
calling  in  an  automatic  fashion. 

Conduct. — The  conduct  of  these  individuals  varies  according 
to  the  profoundness  of  the  mental  weakness.  The  behaviour 
of  the  lowest  type  of  idiot  is  in  keeping  with  his  mental  state  ; 
he  is  totally  incapable  of  looking  after  himself  and  is  unable 
to  dress  or  feed  himself.  In  the  next  grades  one  child  is 
obedient  and  easy  to  manage,  while  another  is  sullen  and 


IDIOCY  AND  IMBECILITY  349 

passionate.  In  some  of  the  feeble-minded,  errors  of  conduct 
may  be  the  only  feature  which  distinguishes  them  from  the 
normal  individual.  A  child  of  this  class  may  be  apparently 
bright  and  quick  at  acquiring  knowledge,  and  yet  fail  to 
keep  himself  clean  or  attend  to  the  calls  of  nature.  The 
various  defects  of  conduct  common  to  the  feeble-minded 
are  too  numerous  to  detail  here,  but  they  range  from  failure 
to  attend  to  the  humblest  functions  of  the  body  to  an  inability 
to  acquire  a  knowledge  of  the  social  and  moral  laws  of  the 
community  ;    they  may  be  errors  of  omission  or  commission. 

Judgment. — The  judgment  of  imbeciles  is  always  defective. 
A  sound  judgment  is  dependent  upon  the  possession  of  many 
attributes  and  the  proper  working  of  these  attributes.  A  keen 
observation,  a  good  memory,  and  an  absence  of  strong  emo- 
tional feelings,  all  go  to  make  sound  judgment ;  and  as  these 
are  quahties  which  are  absent  in  most  of  the  feeble-minded, 
their  judgment  must  suffer  in  consequence. 

Physical  Symptoms.  —  The  physical  changes  commonly 
observed  in  idiocy  and  imbecihty  are  those  which  are  fre- 
quently spoken  of  as  the  physical  stigmata  of  degeneration, 
and  include  abnormalities  and  deformities  in  almost  every 
part  of  the  body. 

Bones. — The  stature  is  frequently  undersized,  and  the  long 
bones  are  unduly  cm'ved.  The  skull  may  be  abnormally 
large  or  very  small,  or  it  may  be  misshapen  and  asymmetrical. 
The  shape  of  the  head  varies  greatly  in  different  types  of 
imbeciles.  The  forehead  may  be  receding,  making  the  head 
appear  to  be  pointed.  The  occipital  region  is  often  small, 
giving  the  back  of  the  head  a  flattened  appearance.  The 
cranial  sutures  may  ossify  too  early  or  the  union  may  be 
delayed  ;  in  the  latter  cases  there  may  be  marked  ridges 
of  bone  formed.  The  palate  is  usually  high,  narrow,  and 
V-shaped.  The  lower  jaw  is  receding  and  this  alone  gives  a 
weak-minded  appearance.  The  ribs  are  rickety  :  the  chest 
is  deformed  and  not  uncommonly  pigeon-breasted. 

Teeth. — The  teeth  are  badly  formed  and  dentition  is  late. 
They  are  frequently  crowded  together  and  may  not  show  the 
full  complement.  They  readily  decay,  and  in  some  instances 
the  enamel  is  not  properly  formed. 

Eyes. — The  orbits  may  be  too  close  together  or  too  widely 


350  PSYCHOLOGICAL  MEDICINE 

separated.  The  eyes  may  be  obliquely  placed  and  the  pupils 
oval  in  shape.  Strabismus  and  other  disorders  of  the  A-isual 
apparatus  ma}'  be  found,  but  these  have  already  been 
mentioned. 

Ears. — The  conformation  of  the  ears  frequentty  exhibits 
marked  defects.  For  example,  they  may  be  set  too  far  back, 
the  pinna  be  badly  formed,  and  the  rim  or  helix  absent ; 
abnormalities  of  shape  and  size  may  be  noted  in  all  or  some 
of  the  other  prominences  and  ridges,  and  in  the  fossee  ;  these 
have  been  described  elsewhere. 

Heart  and  Circulation. — The  heart  may  be  small,  and  there 
may  be  congenital  malformation  of  one  or  more  of  the 
valves.  The  circulation  is  feeble  and  the  fingers  and  toes 
are  cyanosed. 

Bespiration. — The  respiratory  movements  are  shallow,  and 
there  is  a  deficient  entry  of  air  into  the  chest ;  this  fact,  to- 
gether with  the  bad  nutritional  state  so  common  in  the  feeble- 
minded, renders  them  especially  hable  to  phthisis  and  other 
diseases  of  the  chest. 

Gastro-intestinal  Canal. — The  papillse  of  the  tongue  are 
hypertrophied.  The  tonsils  are  frequently  large,  and  the 
naso -pharyngeal  passages  are  filled  with  adenoids.  Food  is 
not  properly  masticated.  The  bowels  may  be  constipated,  but 
at  times  these  patients  suffer  from  obstinate  diarrhoea. 

Skin  and  Appendages. — The  skin  is  frequently  coarse 
and  the  subcutaneous  tissue  tliickened.  The  hair  is  brittle ; 
it  is  absent  from  the  face  of  the  male  idiot,  but  the  female  not 
uncommonly  exhibits  a  downy  growth.  Pubic  hair  is  usually 
absent.     The  nails  are  brittle  and  ridged. 

Sexual  Organs. — The  sexual  organs  are  not  infrequently 
malformed,  the  following  being  the  most  common  defects  ; 
undescended  testis,  genitals  undeveloped,  hj^pospadias  and 
epispadias,  and  in  the  female  atresia  of  the  vagina  and  un- 
developed ovaries  ;  menstruation  is  delaj^ed  or  entirely  absent. 

The  sexual  instinct  is  absent  or  very  weak  in  many  idiots, 
but  in  a  large  number  of  imbeciles  it  is  abnormally  strong  or 
may  exhibit  perversion.  Mastm'bation  and  other  vicious 
practices  are  connnon. 

Nervous  System.  —  The  nervous  system  presents  many 
sensory,    motor,    and    central    defects.      Sensation    is    dulled 


IPIOCY  AND  IMBECILITY  351 

and  the  superficial  reflexes  are  cli'.i.inished.  Saliva  dribbles 
from  the  mouth,  the  normal  pharyngeal  reflex  being  absent. 
The  bladder  and  rectum  empty  themselves  periodically 
and  uncontrolled,  but  the  fault  is  usually  central  and  not 
spinal.     The  reaction  times  are  all  slow. 

The  motor  disorders  are  numerous  and  very  instructive. 
The  microkinetic  or  spontaneous  uncontrolled  movements 
normally  seen  in  infants  are  absent  or  deficient  in  the  idiot. 
Some  children  are  absolutely  motionless,  but  others  are  in 
constant  movement.  The  movements  of  idiots  are  more  auto- 
matic and  regular  than  the  spontaneous  actions  of  a  healthy 
child.  The  body  may  be  swayed  backwards  and  forwards,  or 
constantly  rotated,  or  violently  jerked  from  side  to  side.  The 
fingers  and  hands  may  never  remain  quiet,  the  movements 
consisting  of  twitching  or  slow  flexion  and  extension.  Some 
imbeciles  hold  their  hands  against  their  face,  gently  moving 
their  fingers  over  the  eyes  and  nose.  The  voluntary  move- 
ments are  slow  and  badly  performed.  They  are  very  late  in 
learning  to  walk.  Co-ordination  is  faulty,  and  the  finer  adjust- 
ments cannot  be  performed,  or  are  accomplished  with  great 
difficulty.  This  is  the  cause  why  some  of  these  children  are 
not  able  to  dress  themselves. 

Idiots  and  imbeciles  exhibit  almost  every  degree  of  muscular 
weakness,  paresis,  paralysis,  hemiplegia  ;  or  there  may  be  a 
general  debility,  which  renders  standing  or  walking  impossible. 
Tremor  is  also  a  common  symptom.  The  higher  types  of 
mental  enfeeblement  do  not  exhibit  any  of  these  defects. 

Speech. — At  all  times  speech  is  slow  to  develop  in  children 
who  exhibit  signs  of  feeble-mindedness.  Most  idiots  and 
many  imbeciles  never  progress  further  than  to  employ  a 
gesture-language,  or  at  most  a  few  simple  words.  Sollier  has 
divided  idiots  who  exhibit  mutism  into  two  classes  :  (1)  those 
who  can  understand  what  is  said  to  them,  but  cannot  speak 
themselves  ;  (2)  those  who  can  neither  speak  nor  understand. 
Some  weak-minded  children  never  acquire  a  proper  language, 
but  coin  words  of  their  own,  which  they  always  use  to 
designate  the  same  thing.  It  is  extraordinary  how  quick  mothers 
and  nurses  become  m  learning  what  these  sounds  mean,  for 
at  times  they  are  nothing  more  than  guttural  explosions. 
The  failure  to  acquire  the  faculty  of  speech  is  due,  in  the  vast 


352  PSYCHOLOGICAL  MEDICINE 

majority  of  cases,  to  defects  in  the  brain  itself,  and  is  not  the 
result  of  respiratory  or  laryngeal  deformities.  The  child  who 
understands  language,  but  on  account  of  some  error  in  the 
executive,  is  unable  to  speak  himself,  is  always  more 
teachable  than  the  idiot  who  can  neither  speak  nor  under- 
stand. Deaf-mutism  is  rare  in  idiocy.  In  many  imbeciles 
the  voice  is  harsh  and  monotonous.     Stammering  is  common. 

Handwriting. — Handwriting  is  a  difficult  accomplishment, 
as  it  not  only  requires  knowledge  of  letters  and  words,  but  the 
muscular  movements  are  very  complicated,  and  to  form  letters 
properly  a  high  degree  of  co-ordination  is  requisite.  Now, 
many  of  these  essentials  are  lacking  in  the  idiot,  and  con- 
sequently he  cannot  write.  Some  of  the  feeble-minded  will 
draw  and  copy  figures  or  signs,  but  as  symbols  they  mean- 
nothing  to  them.  Mirror-writing  is  easily  acquired  by  some 
imbeciles  ;  it  is  usually  produced  by  the  left  hand  and  is 
written  from  right  to  left.  In  all  writing  the  upstrokes  and 
downstrokes  are  of  the  same  thickness,  as  the  child  presses 
the  pencil  heavily  on  the  paper. 

Expression. — It  is  not  common  to  see  an  imbecile  who  has 
beautiful  features,  but  occasionally  they  are  met  with  in  the 
higher  types  of  feeble-mindedness.  The  features  are  usually 
coarse  or  very  small,  and  the  head  misshapen.  Tlie  ex- 
pression varies  greatly  ;  some  of  the  more  intellectual  are 
bright  and  cheerful,  but  the  great  majority  have  a  degraded 
appearance.  Some  are  always  grimacing,  some  laughing, 
others  look  bad-tempered  and  forbidding.  The  expression 
may  be  vacant  and  devoid  of  any  animation.  Many  idiots 
seldom  nKDve  their  eyes  without  moving  their  head.  The 
posture  of  the  body  and  limbs  is  usually  awkward  and  clumsy, 
and  the  gait  is  waddling. 

Sleep. — Some  of  these  individuals  Sleep  by  night  and  day 
and  are  always  drowsy  ;  in  others  the  condition  is  rather  one 
of  over-activity,  the*  hours  passed  in  sleep  being  few.  The 
sleep  of  the  feeble-minded  may  be  defective  in  quality,  and 
the  child  may  be  disturbed  by  dreams  and  night  terrors. 

Varieties. — The  usual  types  of  idiocy  described  are  :  (1) 
Genetous ;  (2)  Mongolian ;  (3)  Microce'phalic ;  (4)  Hydro- 
ceflialic  ;  (5)  Hypertrojphic  ;  (6)  Edampsic  ;  (7)  E'piU'ptic  ; 
(B)   Paralytic ;    (9)    Traumatic ;    (10)   Inflammatory  or  Post- 


IDIOCY  AND  IMBECILITY  353 

febrile ;     (11)    Syphilitic ;     (12)    Cretinoid ;     (13)    Idiocy  from 
deprivation  of  senses. 

(1)  Genetous. — Genetous  idiocy  is  the  name  given  by  Ireland 
to  that  class  of  congenital  idiot  which  does  not  rightly  fall 
under  any  other  division,  the  cause  not  being  traceable  during 
life.  There  is  probably  some  hereditary  defect.  There  may 
be  no  deformity  of  head  or  limbs,  but  many  are  of  short  stature. 
The  i3alate  is  highly  arched  and  the  teeth  decayed  ;  the  ears 
are  large  and  defective  ;  the  child  is  dull  with  a  degraded 
expression  ;  the  gait  is  clumsy  and  shuffling.  The  circulation 
is  feeble  and  chilblains  are  common.  In  brief,  the  genetous 
idiot  presents  many  mental  and  physical  stigmata.  Kickets 
and  scrofula  are  frequently  associated  with  this  condition. 
Automatic  movements  are  common.  The  prognosis  as  to 
possibility  of  training  is  fairly  good  in  cases  of  genetous  idiocy 
when  the  child  is  well  nourished  with  good  circulation,  and 
when  the  tactile  sensibility  is  good  and  the  power  of  concen- 
tration of  attention  is  present. 

(2)  Mongolian. — The  Mongolian  type  of  idiocy  belongs  to 
the  class  of  genetous  idiots  and  is  so  named  from  the  close 
resemblance  of  the  physiognomy  of  these  cases  to  that  of  the 
Chinese.  The  head  is  usually  small  and  rounded  with  broad 
features  and  obliquely  placed  eyes.  The  nose  is  flattened. 
The  hands  and  feet  are  broad.  The  figure  is  squat,  giving  a 
dwarfish  appearance.  The  fungiform  papillae  of  the  tongue 
are  hypertrophied.  Dentition  is  very  late.  The  skin  is  dry 
and  harsh.  The  Mongolian  idiot  is  usually  good-tempered, 
but  exhibits  very  little  intellect.  He  is  very  imitative  and 
easily  pleased.  Many  have  organic  disease  of  the  heart  and 
feeble  circulation.     The  prognosis  is  usually  far  from  good. 

(3)  Microcephalic. — The  microcephalic  type  comprises  those 
cases  in  which  the  head  is  unduly  small.  When  the  cir- 
cumference of  the  head  is  less  than  seventeen  inches,  the  con- 
dition always  connotes  idiocy.  But  it  must  be  borne  in  mind 
that  idiocy  is  produced  rather  by  disease  than  the  smallness 
of  the  brain.  The  head  is  narrow  and  oxycephalic  in  shape. 
Idiots  of  this  type  are  usually  unduly  active  with  restless 
movements.  They  are  late  in  learning  to  walk.  They  are 
very  deficient  in  mental  capabilities,  as  they  have  little  or 
no    power    of    attention.     Some    are    very    quarrelsome   and 

23 


354  PSYCHOLOGICAL  MEDICINE 

spiteful,  others  are  more  easily  managed  and  even  become 
affectionate  towards  those  who  tend  them.  They  have  no 
sense  of  shame.  They  frequently  show  pleasure,  and  may 
be  very  imitative,  and  are  fond  of  music.  The  prognosis  is 
decidedly  bad. 

(4)  Hijdroce-phalic. — The  hydrocephalic  type  is  apt  to  be 
confused  with  the  hypertrophic,  but  the  shape  of  the  head 
differs  in  certain  particulars.  A  large  cranium  does  not  always 
connote  hydrocephalus  and  many  normal  children  have 
abnormally  large  heads.  The  hydrocephalic  head  is  rounded 
in  shape,  as  the  antero-posterior  and  transverse  diameters  are 
nearly  the  same  in  measurement.  The  widest  circumference 
is  usually  at  the  temples.  The  width  between  the  eyes  is 
increased.  The  head  in  the  child  with  rickets  may  be  con- 
founded with  hydrocephalus,  but  in  the  former  the  antero- 
posterior diameter  is  lengthened  and  the  fontanelle  is  depressed, 
while  in  the  hydrocephalic  head  it  is  raised.  Hydrocephalus 
may  be  congenital,  or  may  be  acquired  during  the  early  years 
of  life,  and  it  may  be  either  acute  or  chronic.  Hydrocephalus 
may  cause  early  death.  In  some  cases  recovery  may  take 
place,  but  if  it  persists  and  the  child  lives,  the  damage  to  the 
brain  usually  causes  idiocy.  Pressure  may  give  rise  to  deafness 
or  impairment  of  vision.  These  children  are  generally  good- 
tempered  and  friendly.  They  move  slowly,  and  speech  is 
harsh  and  monotonous.  Growth  is  often  interfered  with,  and 
in  consequence  this  type  of  idiot  is  short  in  stature.  Some 
of  them  can  be  taught  to  read  and  write,  but  the  moral  sense 
is  usually  defective.  The  gait  may  be  unsteady,  or  they  may 
be  unable  to  walk  at  all.     The  prognosis  is  bad. 

(5)  Hypertwphic. — In  the  hypertrophic  idiot  the  head  is 
square-shaped  or  elongated  in  the  antero-posterior  diameter, 
the  greatest  width  being  above  the  superciliary  ridges.  The 
liypertrophic  head  does  not  attain  to  so  large  a  size  as  is  found 
in  some  cases  of  hydrocephalus.  The  condition  is  a  rare  one 
and  usually  develops  during  the  early  years  of  life.  Mentally 
these  children  are  dull  and  they  are  slow  in  performing 
movements.    Headache  is  often  a  prominent  symptom. 

(6)  Eclam'psic. — In  eclampsic  cases  of  idiocy  convulsions 
develop  in  infancy  from  teething  or  some  similar  stress.  They 
may  continue  with  more  or  loss  frequency  for  some  months 


IDIOCY  AND  IMBECILITY  355 

or  years  and  then  disappear,  but  their  effect  on  the  brain  may 
be  so  serious  as  to  leave  the  child  idiotic  or  imbecile.  He  is 
usually  excitable  and  passionate  and  on  account  of  the  low 
degree  of  attention  is  generally  unteachable.  He  may  appear 
bright,  and  may  be  clever  at  imitation,  with  quick  and  restless 
movements.  The  moral  sense  is  undeveloped  and  there  is 
no  sense  of  shame.  The  prognosis  largely  depends  on  the 
extent  and  severity  of  the  convulsions. 

(7)  Efileptic. — Epilepsy  always  tends  to  produce  weak- 
mindedness,  whether  by  a  process  of  dissolution  or  by  inter- 
ference with  evolution.  Epilepsy  may  appear  at  any  time, 
but  in  the  majority  of  cases  of  epileptic  idiocy  the  fits  first 
show  themselves  at  the  time  of  teething.  Shuttleworth  and 
Fletcher  Beach  ^  describe  three  classes  of  epileptic  idiots : 
'  (a)  Bright,  well-made  children,  who  progress  at  school,  and 
take  an  interest  in  their  work,  whether  educational  or  in- 
dustrial ;  (&)  Also  well-informed  children,  who  are  very  listless, 
but  can  talk  and  take  an  interest  in  what  goes  on  around 
them.  They  usually  make  fair  progress,  but  when  doing  well 
a  succession  of  fits  comes  on  and  throws  them  back,  so 
that  for  a  time  they  become  lost  and  dazed  ;  (c)  These  have 
a  more  animal  type  of  face,  are  dull,  and  in  consequence  of 
the  frequent  fits  make  no  progress  whatever.'  Many  of  these 
children  are  irritable  and  violently  impulsive,  and  they  form 
one  of  the  largest  divisions  of  idiocy.  The  prognosis  varies 
with  the  frequency  of  the  seizures,  but  as  a  class  they  are 
very  disappointing. 

(8)  Paralytic. — Paralytic  idiocy  is  due  to  coarse  lesions  of 
the  brain,  the  most  common  of  which  is  the  result  of  a  haemor- 
rhage at  birth  or  during  early  infancy  The  paralysis  is  usually 
one-sided,  and  there  is  a  spastic  rigidity  of  the  muscles.  The 
arm  is  generally  more  paralysed  than  the  leg.  The  mental 
faculties  are  impaired  in  the  majority  of  cases,  but  in  a  fair 
percentage  much  good  can  be  done  by  training. 

(9)  Traumatic. — Traumatic  idiocy  is  produced  by  a  blow  on 
the  head,  a  fall,  or  some  prolonged  pressure  on  the  skull,  such 
as  may  occur  during  a  protracted  labour  in  a  woman  with  an 
abnormally  small  pelvis.  The  degree  of  mental  enfeeblement 
is  to  a  large  extent  dependent  upon  the  amount  of  damage  to 

^  Allbutt's  System  of  Medicine,  'Idiocy  and  Imbecility,'  vol.  iii. 


356  PSYCHOLOGICAL  MEDICINE 

brain-structure,  but  in  some  instances  an  apparently  slight 
injury  is  followed  by  serious  symptoms.  The  child  is  usually 
normal  until  it  has  some  fall  or  injury,  after  which  the  mental 
development  is  affected.  Some  of  these  children  are  strong 
physically,  and  even  learn  to  read  and  write,  but  they  are  always 
backward,  and  when  they  reach  adolescence  their  mind  is 
equal  to  that  of  a  child  of  six  or  eight.  In  those  cases  where 
the  injury  takes  place  at  the  time  of  birth,  as  for  example 
during  the  employment  of  forceps,  the  degree  of  idiocy  may 
be  very  profound. 

(10)  Inflammatory. — Inflammatory  idiocy  is  usually  the 
result  of  inflammation  of  the  brain  and  its  membranes, 
the  condition  being  set  up  by  some  complication  occurring 
at  the  time  of  or  immediately  following  diseases  such  as 
scarlet  fever,  typhoid,  measles,  or  whooping-cough.  The  degree 
of  feeble-mindedness  is  dependent  upon  the  extent  of  the 
damage  to  the  brain.  Many  of  these  children  greatly  improve 
with  proper  training.  If  the  brain  is  seriously  injured,  the 
child  remains  degraded  and  uncontrollable. 

(11)  SyjpJiilitic. — Idiocy  due  to  congenital  syphilis  is  found 
to  be  more  common  than  authorities  originally  supposed.  The 
Wassermann  test  has  proved  invaluable  in  diagnosing  these 
cases.  The  child  may  or  may  not  exhibit  symptoms  common 
to  syphilitic  children  and  frequently  develops  normally  until 
about  ten  years  of  age,  when  convulsive  seizures  supervene, 
and  from  this  time  onwards  there  is  not  only  no  further  mental 
development  but  a  definite  deterioration. 

(12)  Cretinoid  Idiocy. — Cretinoid  idiocy  has  already  been 
described  under  cretinism. 

(13)  Idiocy  from  Deprivation  of  Senses. — In  order  to  pro- 
duce idiocy  purely  from  the  deprivation  of  senses,  two  or  more 
important  senses,  such  as  sight  and  hearing,  must  as  a  rule 
be  absent.  It  is  possible  to  teach  these  children,  but  the  time 
and  labour  required  are  very  great,  as  progress  is  slow  and 
tedious.  Blindness  invariably  occurs  in  the  cases  known  as 
*  amaurotic  family  history,'  but  in  these  patients  the  blind- 
ness is  a  concomitant  symptom  and  not  the  cause  of  the 
idiocy. 

Moral  Imhccility. — Moral  imbecility  is  described  elsewhere. 
Diagnosis  of  Idiocy. — The  diagnosis  of  idiocy  is  not  always 


IDIOCY  AND  IMBECILITY  357 

easy  in  infants,  but  there  are  one  or  two  points  which  help 
the  physician  in  forming  a  diagnosis.  The  infant  may  not 
take  the  breast  Hke  the  normal  child  and  may  have  to  be  fed 
with  a  spoon.  Another  important  symptom,  and  not  un- 
commonly the  first  indication  that  all  is  not  well,  is  that  the 
usual  microkinetic  movements  are  absent,  the  infant  lying  in 
his  cot  and  rarely  moving.  As  months  pass  the  diagnosis 
becomes  easier.  Late  dentition,  late  development  of  speech, 
and.  late  learning  to  walk  are  all  symptoms  which  should  cause 
the  physician  to  suspect  idiocy  or  imbecility.  Fits  of  violent 
and  uncontrolled  passion  are  suggestive  of  mental  enfeeble- 
ment.  The  presence  of  any  physical  stigmata  should  be 
observed.  Parents  naturally  try  to  prove  that  their  child  is 
normal,  and,  laying  stress  on  his  better  qualities,  make  light 
of  his  deficiencies.  Test  the  child  carefully  yourself.  Note 
whether  he  reacts  to  stimuli  of  sight  and  hearing  or  other 
sensory  impressions.  Exainine  the  conformation  of  the  head 
and  test  the  intellectual  powers,  comparing  them  with  the 
faculties  of  a  normal  child  of  a  corresponding  age  and  social 
status.  Inquire  for  any  history  of  convulsions  or  head- 
injury. 

General  Pathology  and  Pathological  Anatomy. — There 
are  a  great  variety  of  changes  to  be  found  in  the  skulls  and 
brains  of  idiots,  of  which  the  following  are  the  most  common. 
The  skull-cap  may  be  abnormally  thickened  or  thinned,  and 
when  held  up  to  the  light  may  be  found  to  be  diaphanous  in 
places.  Usually  in  those  cases  where  the  brain  is  unilaterally 
atrophied,  the  skull-cap  will  be  found  to  be  greatly  thickened 
on  the  side  where  the  brain  is  wasted.  The  shape  of  the  skull 
may  be  abnormal,  the  condition  being  dependent  upon  early 
or  late  closing  of  the  various  sutures.  Wormian  bones  are 
not  uncommonly  found.  The  membranes  may  be  thickened 
and  opaque  in  appearance.  The  dura  mater  may  be  adherent 
to  the  skull.  The  pia  mater  may  contain  miliary  tubercles. 
The  sub-arachnoid  fluid  may  be  greatly  increased  and  the 
ventricles  dilated. 

The  convolutions  of  the  brain  itself  may  be  more  simple  in 
arrangement  than  in  the  normal  individual.  The  cerebrum 
may  be  abnormally  small  and  atrophied,  while  the  cerebellum 
may  not  be  correspondingly  diminished.     Hypertrophy  of  the 


358  PSYCHOLOGICAL  MEDICINE 

brain  substances  is  less  frequently  seen  and  is  usually  clue  to 
a  large  increase  in  the  neuroglia. 

Sclerosis  of  the  brain  may  be  either  diffuse  or  in  disse- 
minated patches,  the  former  being  more  common.  Shuttle- 
worth  and  Fletcher  Beach,  in  their  monograph  on  Idiocy  and 
Imbecility  in  Albutt's  '  System  of  Medicine,'  describe  this 
condition  as  follows  :  '  It  involves  a  considerable  part  of  one 
hemisphere  and  is  not  distinctly  circumscribed  ;  the  medullary 
substance  is  chiefly  affected.  The  frontal,  ascending  frontal, 
ascending  parietal  and  occipital  convolutions  are  those  which 
are  mostly  implicated.  The  white  matter  is  hard,  and  looks 
on  section  like  the  white  of  an  egg,  though  sometimes  there 
is  a  honeycombed  appearance.  The  increased  hardness  and 
density  is  due  to  an  overgrowth  of  the  neuroglia,  which  com- 
presses the  nerve-fibres  and  finally  causes  their  disappearance. 
The  disease  is  due,  no  doubt,  to  a  chronic  inflammation  of 
the  membranes,  and  we  find  on  examination  increase  and  dis- 
tension of  the  blood-vessels,  infiltration  of  the  perivascular 
sheaths  with  leucocytes,  which  sometimes  make  their  way  into 
the  surrounding  tissue,  and  occasionally  an  increase  of  the  fibrous 
tissue  around  the  vessels.  In  disseminated  sclerosis  patches 
are  found  scattered  throughout  the  cerebrum,  cerebellum,  basal 
ganglia,  pons,  medulla,  and  spinal  cord.  The  convolutions  of 
the  brain  are  usually  exempted.  The  patches  are  circum- 
scribed and  tough,  and  in  the  spinal  cord  vary  in  size  from  a 
pin's  head  to  a  hazel-nut ;  they  are  usually  large  in  the  brain- 
matter  itself.  The  meninges  of  the  brain  and  spinal  cord  may 
be  healthy,  or  there  may  be  signs  of  congestion  or  chronic 
inflammation.  The  cerebro-spinal  fluid,  which  is  increased, 
is  sometimes  cloudy,  and  the  lateral  ventricles  are  dilated.'  On 
the  other  hand,  the  brain  substances  may  be  softened  in  places, 
usually  as  the  result  of  some  defect  in  the  circulation. 

Porencephaly  is  a  rarer  condition  than  most  of  those  just 
described.  The  term  was  first  used  by  Heschl.  The  condi- 
tion may  be  either  congenital  or  acquired.  The  congenital 
form  usually  develops  about  the  sixth  month  of  intra-uterine 
life.  There  may  be  a  cavity  on  the  surface  involving  one  or 
both  hemispheres,  and  it  usually  communicates  with  the  lateral 
ventricles.  Cysts  may  be  scattered  aljout  in  different  regions, 
the  most  common  being  frontal,  ascending  frontal,  and  ascend- 


IDIOCY  AND  IMBECILITY  359 

ing  parietal,  temporo-sphenoidal,  and  occipital  gyri.  There  is 
usually"  paralysis  of  the  limbs  on  the  opposite  side,  the  severity 
depending  on  the  extent  of  the  damage  to  the  brain.  Some 
of  the  above  cavities  may  be  the  result  of  small  hsemor- 
rhages.  The  tumours  of  the  brain  are  in  the  great  majority 
of  cases  tuberculous  in  nature.  Gliomata  are  more  rarely 
met  with. 

The  microscopic  changes  found  in  the  brain  of  idiots  con- 
sist largely  of  nerve-cell  changes.  The  cortex  is  very  narrow, 
being  about  half  its  normal  size.  The  nerve-cells  are  rounded 
and  are  deficient  in  processes,  or  the  processes  exhibit  de- 
generative variations.  The  number  of  cells  is  also  reduced, 
and  the  several  layers  are  not  clearly  differentiated.  The 
association-fibres  are  greatly  diminished  in  number.  The 
following  are  the  most  noticeable  changes  found  in  the  various 
types  of  idiocy. 

(a)  Genetous  Types. — The  skull  is  often  abnormally  thin 
or  thick.  The  convolutions  are  single  in  arrangement  and 
frequently  narrower  than  usual,  the  frontal  convolutions  often 
appear  very  small.  The  cerebrum  may  not  properly  cover  the 
cerebellum,  the  latter  being  in  proportion  larger  than  the  former. 
The  base  of  the  brain  may  be  asymmetrical.  The  corpus  cal- 
losum  may  be  entirely  absent.  Microscopically  the  nerve-cells 
will  be  found  to  be  deformed  in  shape  and  few  in  number,  and 
the  whole  neuron  is  degenerate.  Fatty  granular  cells  are  met 
with.  There  is  frequently  great  neuroglia  proliferation.  The 
association-fibres  are  few  and  less  complex,  and  the  vessels 
are  small  and  degenerate. 

(h)  Microcephalic. — The  cerebral  hemispheres  are  small 
and  ill  developed,  and  portions  of  the  encephalon  may  be 
absent.  The  cerebellum  is  large  in  proportion  to  the  rest  of 
the  brain.  The  brain  may  be  asymmetrical  and  the  convolu- 
tions simple  in  arrangement.  The  frontal  gyri  are  excep- 
tionally small.  The  microscopic  changes  are  such  as  occur 
with  failure  of  development  and  degeneracy. 

(c)  Hydroceplialic. — As  this  may  be  either  congenital  or 
acquii'ed,  the  morbid  changes  vary  according  to  the  cause. 
The  cranial  bones  are  usually  greatly  thinned.  The  circum- 
ference of  the  head  may  reach  very  large  proportions.  The 
intra-cranial  fluid  is  much  increased  and  may  weigh  as  much 


360  PSYCHOLOGICAL  MEDICINE 

as  twenty  pounds.  This  fluid  is  slightly  albuminous,  has  a 
specific  gravity  of  about  1010,  and  is  mostly  contained  in 
the  distended  lateral  and  third  venticles.  The  pressure  may 
lead  to  atrophy  of  the  surrounding  portions  of  the  brain. 

(d)  Hypertrofldc. — This  condition  is  due  to  great  increase 
in  the  white  matter.'  The  convolutions  are  flattened.  The 
chief  seats  of  the  disease  are  to  be  found  in  the  two  hemi- 
spheres, and  more  rarely  in  the  corpora  striata  and  optic 
thalami. 

(e)  Eclampsic. — This  condition  is  very  obscure.  Ireland 
writes  that  he  is  inclined  to  think  that  the  lesions  most  com- 
monly observed  are  adhesions  of  the  membranes,  some  wasting 
of  the  gyii,  especially  of  the  frontal  ones,  and  greater  hardness 
and  toughness  of  the  brain-tissue  than  is  usual. 

(/)  E'pile]jtic. — No  pathological  changes  are  known  which 
can  be  described  as  pathognomonic  of  epilepsy,  but  the  brains 
of  epileptic  idiots  show  changes  which  are  the  result  of  faikne 
of  development  and  which  are  not  peculiar  to  this  condition. 
Bevan  Lewis  has  described  the  inflated  spheroidal  cell  so 
commonly  found  in  the  brains  of  epileptic  idiots,  and  Andriezen 
confirms  Bevan  Lewis's  observations,  that  he  believes  the 
morbid  process  underlying  epileptic  idiocy  to  be  a  hardening 
of  the  nem'oglia  fibre-cells  with  destruction  and  atrophy  of 
the  nerve-cells. 

{g)  Paralytic. — This  is  usually  brought  about  by  haemor- 
rhage in  the  cerebral  tissue,  and  is  frequently  occasioned  by 
some  degenerative  change  in  the  cerebral  blood-vessels. 

{h)  Syphilitic. — In  individuals  dying  from  syphilitic  idiocy, 
the  cranial  bones  and  membranes  are  usually  found  to  be 
thickened.  The  blood-vessels  may  show  a  condition  of  en- 
darteritis, which  in  tm'n  has  given  rise  to  atrophy  of  the 
nervous  tissues. 

Treatment  o£  Idiocy. — The  treatment  of  idiocy  and  im- 
becility covers  a  wide  field,  including  as  it  does,  not  only  the 
treatment  of  the  various  factors  which  may  have  given  rise  to 
the  failure  of  mental  development,  but  also  the  physical,  in- 
tellectual, and  moral  training  of  the  afflicted  individual. 

If  there  is  any  apparent  cause  for  the  idiocy,  it  must  be 
treated.  Next  attend  to  the  nutrition  of  the  body  and  care- 
fully regulate  the  diet.     The  food  should  be  simple  and  farina- 


IDIOCY  AND  IMBECILITY  361 

ceous  in  nature.  Meat  should  be  limited.  Many  idiots  will  eat 
to  excess,  if  allowed  to  do  so,  and  their  meals  should  be  super- 
vised by  a  nurse  or  some  responsible  person.  The  clothing 
should  be  light  but  warm  in  texture,  as  these  children  are  sensi- 
tive to  cold.  The  teaching  of  cleanliness  is  frequently  difficult, 
and  it  may  take  many  months  of  training  before  the  nurse  is 
rewarded  by  the  child  giving  some  sign  when  he  wants  to  attend 
to  the  calls  of  nature.  If  the  patient  is  an  adult,  bathing  him 
in  cold  water  or  depriving  him  of  some  luxury  every  time  he 
offends  may  act  as  a  stimulus  to  his  memory  on  subsequent 
occasions.  Further,  the  child  must  be  taught  to  wash  and 
dress  himself.  Cleanliness  can  be  acquired  by  carrying  out  the 
ablutions  at  regular  times,  and  a  nurse  should  stand  near  and 
see  that  the  operations  are  thorough  and  effective.  Physical 
drill  and  exercises  are  very  important,  but  care  should  be  taken 
not  to  exhaust  the  patient. 

The  mental  training  should  be  started  gradually,  the  first 
aim  being  to  develop  the  acuteness  of  the  various  senses  and 
strengthen  the  powers  of  attention.  The  sense  of  sight  can 
be  cultivated  by  using  coloured  balls  and  making  the  child 
place  them  in  cavities  of  the  same  colour.  Matching  bricks 
or  wool  is  also  a  useful  exercise.  If  the  idiot  has  difficulty  in 
concentrating  the  attention,  use  bright  and  glittering  objects. 
The  sense  of  hearing  is  developed  by  musical  notes,  bells, 
and  various  sounds  of  the  human  voice.  Touch  should  be 
cultivated  in  the  first  place  by  coarse  movements,  such  as 
putting  ninepins  into  sockets,  passing  buttons  through  button- 
holes, or  lacing  up  a  garment.  Teach  the  difference  between 
smooth  and  rough  articles,  such  as  velvet  and  a  grater  ;  between 
sharpness  and  bluntness,  between  things  round  and  things 
angular.  Appreciation  of  heat  and  cold  is  taught  by  dipping 
the  child's  hand  into  hot  or  iced  water. 

An  important  lesson  to  be  learnt  is  that  fire  burns,  and 
this  should  be  taught  early.  The  difference  between  weight 
and  lightness  can  be  acquired  by  making  the  child  lift  cans 
which  are  filled  with  different  amounts  of  shot.  Later  on 
the  finer  movements  and  adjustments  may  be  taught  by 
getting  him  to  string  some  small  beads,  or  balance  unstable 
articles  on  the  table.  The  senses  of  smell  and  taste  are  not 
so  important,   but  they  should  be  developed  by  sweet  and 


362  PSYCHOLOGICAL  MEDICINE 

nauseous  odours,  and  sweet  or  bitter,  solutions.  If  the  atten- 
tion is  very  def  ecti-ve,  very  little  progress  will  be  made  until  this 
is  more  under  the  child's  control.  The  profound  idiot  must  be 
attracted  b}'  loud  sounds  or  bright  lights,  or  by  heat  and  cold, 
or  mild  electric  shocks. 

Learning  to  walk  is  always  a  greater  effort  to  the  feeble- 
minded than  to  the  normal  child,  and  when  it  is  acquired  the 
act  of  walking  is  commonly  performed  in  a  clumsy  manner. 
With  all  movements  the  defect  in  execution  may  be  due 
either  to  mental  incapacity  to  understand  or  imitate,  or  to 
some  defect  of  the  nervous  or  muscular  system.  Clearly  it  is 
important  to  detect  in  every  given  case  where  the  error  lies.  A 
special  swing  has  been  constructed  for  teaching  the  idiot  how 
to  walk.  In  this  apparatus  the  child  swmgs  with  his  feet  and 
legs  hanging  free,  and  as  he  swings  the  feet  they  lightly  touch 
a  tUted  board,  and  the  child  usually  instinctively  moves  one 
leg  in  front  of  the  other.  Later  the  child  can  be  placed  in  a 
standing  position  leaning  on  some  paraUel  bar  which  moves 
on  wheels.  If  the  muscles  are  weak  they  must  be  massaged 
daily.  Learning  to  speak  is  one  of  the  greatest  obstacles 
imbeciles  have  to  overcome.  They  usually  understand  what  is 
said  to  them  long  before  they  can  express  their  own  thoughts 
in  words  ;  one  of  the  difficulties  being  that  many  of  them  have 
no  ideas  to  express. 

The  respiratory  apparatus  must  be  examined,  and  any 
defects  should  be  rectified,  if  possible.  Remove  adenoids  or 
abnormally  large  tonsils.  Make  the  child  perform  breathuig 
exercises.  The  ear  must  be  trained  to  distinguish  sounds. 
Next  make  the  child  imitate  the  hp  and  tongue  movements 
of  the  teacher.  The  nasal,  lingual,  and  labial  sounds  are 
usually  the  easiest  to  acquire.  The  child  should  be  made  to 
repeat  short  words  after  the  instructor.  The  number  of  words 
that  can  be  learned  varies  greatly  in  different  types  of  idiocy. 
If  a  child  does  not  learn  to  speak  before  he  reaches  the  age 
of  six  or  seven,  his  vocabulary  will  never  be  large.  Some 
children  coin  words  of  their  own,  and  as  a  result  they  are 
somewhat  difficult  to  teach.  Writing  is  the  next  step  to 
be  undertaken  ;  it  is  an  accomplishment  that  may  never  be 
acquired,  as  it  is  a  very  complex  adjustment  and  far  beyond 
the  powers  of  many  idiots.     Make  them  draw  lines  or  figures. 


IDIOCY  AND  IMBECILITY  363 

or  make  tracings.  An  idiot  may  write  a  word  or  even  words 
and  not  understand  what  the  symbols  mean. 

Industrial  education  is  a  factor  of  great  importance  in  the 
training  of  all  classes  of  feeble-minded  individuals.  Object- 
lessons  must  be  the  basis  of  all  teaching,  and  in  this  way  the 
kindergarten  system  is  an  excellent  one.  Many  of  these 
children  who  are  educable  will  be  found  to  have  special  apti- 
tude for  different  varieties  of  work.  One  will  be  quick  at 
learning  carving  or  basket-making,  and  yet  be  quite  unable  to 
acquire  other  accompHshments,  however  simple.  The  teach- 
ing of  one  art  alone  is  not  always  the  best  form  of  education, 
but  here  the  instructor  must  be  left  to  decide  in  each  particular 
case.  There  is  a  growing  tendency  in  some  countries  to 
found  colonies  for  the  feeble-minded  where  they  can  either  be 
taught  for  a  number  of  years,  or  where  they  may  live  out 
their  hves  in  a  self-supporting  settlement.  Farming  and 
horticulture  are  useful  occupations  for  these  patients,  who 
with  proper  supervision  may  become  valuable  workers  on  the 
land. 

Moral  training  is  important ;  and  it  can  be  laid  down  as 
a  fundamental  rule  that  more  will  be  done  in  developing  the 
character  of  the  imbecile  by  kindness  than  by  harshness.  He 
is  usually  very  apprehensive  and  easily  frightened.  Unless  a 
person  is  endowed  with  an  enormous  amount  of  patience,  he 
should  not  undertake  the  training  of  the  feeble-minded.  Once 
the  child  is  attached  to  his  teacher,  he  will  show  sorrow  if  he 
displeases  him.  Punishment,  no  doubt,  is  required  at  times, 
but  corporal  chastisement  should  be  avoided  if  possible.  En- 
courage good  behaviour  by  giving  treats  or  luxuries  from  time 
to  time,  but  let  the  delinquent  be  deprived  of  his  pleasures. 
Eemember  that  some  children  are  unable  to  acquire  a  know- 
ledge of  the  moral  code  ;  supervision  should  always  be  careful, 
as  otherwise  serious  catastrophes  may  take  place.  Many  of 
these  patients  will  profess  much,  but  their  actions  often  belie 
their  words.  In  conclusion,  let  it  be  borne  in  mind  that  fre- 
quently the  most  hopeless  ease  may  eventually  learn  some- 
thing. Perseverance  will  often  be  rewarded,  and  the  teacher 
may  see  his  charge  slowly  emerge  from  complete  mental  dark- 
ness to  a  dawn  of  modest  intellectual  enlightenment. 


364  PSYCHOLOGICAL  MEDICINE 

Moral  Imbecility 

Moral  imbecility  is  a  form  of  mental  disorder  that  is  now 
recognised  as  a  type  of  mental  deficiency  and  is  certifiable 
mider  the  Mental  Deficiency  Act,  1913.  The  moral  sense 
is  of  late  development  and  consequently  readily  becomes 
affected  in  disease.  This  sense  may  be  absent,  defective,  or 
altered — ■ 

(a)  In  idiots  and  imbeciles. 

(6)  In  some  children  otherwise  apparently  normal. 

(c)  In  some  men  of  genius. 

(d)  In  epileptics. 

(e)  In  some  cases  as  a  first  symptom  in  impending  mental 
break- down. 

if)  In  some  cases  as  a  result  of  a  former  attack  of  insanity. 

(g)  In  a  condition  of  intoxication. 

The  term  '  moral  imbecility  '  properly  belongs  to  the  class 
of  cases  in  which  the  moral  sense  is  congenitaUy  defective. 
Some  children  differ  from  the  normal  in  that  no  amount  of 
severity  or  kindness  will  teach  them  the  moral  code.  As  the 
child  grows  up,  it  fails  to  acquire  such  attributes  as  truth  and 
virtue.  Both  in  action  and  conversation  we  find  the  child  to 
be  unreliable  ;  in  the  place  of  honesty  we  find  pilfering,  and 
instead  of  truthfulness,  mendacity.  To  such  a  child  there 
is  no  difl'erence  between  me.um  and  taum.  He  sees  some- 
thing, desires  it,  and  takes  it.  Often  it  is  but  the  fleeting 
fancy  of  the  moment  which  prompts  the  act,  and  he  gratifies 
the  impulse.  In  this  way  useless  articles  may  be  thieved, 
and  even  the  thief  himself  can  give  no  adequate  reasori  for 
his  action. 

i'requently,  too,  tiiis  irrespon.^ibiHty  is  coupled  with  great 
canning  in  movements  and  guilelessness  in  conversation. 
It  is  not  surprising  that  to  the  man  in  the  street  such  a  person 
is  an  al^andoned  criminal ;  and  not  only  to  the  man  in  the 
street,  but  to  the  judge  on  the  bench.  To  both  alike,  the 
physician  who  ventures  to  whisper  that  it  is  not  crime  but 
disease  may  well  appear  to  be  himself  insane  or  worse.  For 
all  that,  the  physician  knows  that  it  is  disease  and  v/onders 
whether  it  can  be  just  to  pimish  a  man  for  failing  to  possess 
an  attribute  which  he  never  had,  and  had  not  the  capacity  to 


MORAL  IMBECILITY  365 

acquire.  He  wonders  whether  the  august  representative  of  the 
law  would  be  logical  and  hold  a-  blind  man  to  be  negligent 
who  did  not  see  a  portly  policeman  raise  his  hand  to  bid  him 
stop.  Then  he  tries  to  remeinber  that  the  individual  must 
suffer  rather  than  the  whole  body,  that  it  would  encourage  real 
crime  to  be  lenient  with  seeming  crime,  that  the  line  between 
sanity  and  insanity  in  such  cases  is  ill  defined,  and  all  other 
arguments  that  go  to  show  that  punishment  cannot  always 
be  measured  by  responsibihty.  He  is  sorry  for  the  individual 
nevertheless.  The  difficulty  of  these  questions  is  great  and 
there  is  no  room  here  for  sociological  considerations.  Short, 
however,  of  this  is  the  fact  that  a  want  of  recognition  of  the 
existence  of  such  a  form  of  mental  disorder  or  defect  as  that 
which  is  described  as  moral  imbecility  or  absence  of  moral 
sense,  may  lead  to  miscarriage  of  justice  in  the  form  of  punish- 
ment which  no  social  exigencies  demand. 

Moral  failure  may  show  itself  in  other  ways.  With  the 
onset  of  pubeii:,y  fresh  difficulties  may  arise  and  grave  offences 
against  society  be  perpetrated.  Persons  may  indecently  expose 
themselves,  or  show  other  forms  of  sexual  precocity.  Pyro- 
mania  is  a  form  of  impulse  not  uncommonly  met  wath  in 
individuals  who  are  morally  defective.  False  charges  against 
others  may  be  made  by  these  moral  perverts  ;  women  may 
accuse  men  of  divers  forms  of  rascality,  and  their  evidence 
often  wears  the  aspect  of  truth,  for  they  are  cunning  liars  and 
will  concoct  plausible  tales.  One  may  see  in  om-  com'ts  of 
justice  jmies  disagreeing  on  their  verdict  in  charges  of  this  kind, 
for  there  are  always  men  ready  to  beheve  these  accusations, 
no  matter  how  improbable  or  even  impossible  they  may  be. 

Petit  mal  or  the  major  form  of  epilepsy  must  be  considered 
when  examining  a  case  of  apparent  moral  imbecility,  for  gi'ave 
breaches  of  the  ethical  code  may  follow  seizures  of  this  kind. 
These  persons  seldom  have  any  delusions  and  frequently 
show  great  intellectual  power  in  other  directions.  A  man  of 
such  pronounced  and  even  phenomenal  abilitj^  as  to  be  called 
a  man  of  genius  is  not  uncommonly  morally  defective.  The 
absence  of  any  delusions  does  not  connote  sanity,  for  mental 
disorder  may  show  itself  by  negative  as  well  as  positive 
symptoms. 

Physical  Symptoms. — The  morally  enfeebled  may  exhibit  no 


866  PSYCHOLOGICAL  MEDICINE 

physical  defects,  but  as  they  are  usually  the  offspring  of  de- 
generate parents  we  find  in  a  fair  proportion  of  cases  physical 
stigmata.  The  palate  commonly  is  high,  narrow,  and  unduly 
arched,  and  there  may  be  abnormalities  in  the  skull  or  Umbs. 
On  the  other  hand,  the  physical  development  may  be  good 
and  the  individual  outwardly  normal. 

Diagnosis. — The  history  of  the  case  must  be  the  chief  aid 
to  a  correct  diagnosis.  The  parents  are  usually  very  neurotic 
and  one  of  them  may  have  been  definitely  insane.  Alcoholic 
tendencies,  epilepsy,  or  other  symptoms  of  degeneracy  in  the 
immediate  ancestors  are  points  of  importance  and  should 
be  carefully  recorded.  Marked  nem'oses  in  the  brothers  or 
sisters  frequently  indicate  that  other  forms  of  instability  may 
be  expected  in  the  family. 

The  life-history  of  the  individual  must  be  examined.  As 
a  child,  was  he  addicted  to  lying  or  thieving  ?  In  his  early 
education,  when  corrected,  did  he  express  sorrow  when  he 
sinned  and  was  in  danger  of  punishment,  or  did  he  quickly  forget 
and  offend  in  the  same  way  at  the  very  next  temptation  ? 
Was  he  of  precocious  development,  maturing  rapidly  and 
brilHantly  in  certain  directions,  but  abnormally  backward  in 
others  ?  Or  was  he  always  behind  other  children  of  a  similar 
age,  late  in  learning  to  walk,  late  in  learning  to  speak,  slow 
in  acquiring  the  various  attributes  which  go  to  make  the 
normal  mind,  or  capable  of  acquhing  only  the  most  humble 
of  these  and  altogether  failing  to  attain  the  highest  ?  The 
morally  unsound  are  usually  wayward  and  volatile.  They 
commonly  either  ignore  authority  or  recognise  its  controlling 
influence  only  when  present.  ^Vhen  puberty  was  reached 
were  there  acts  of  gross  immorality  ?  Or  was  the  individual 
dismissed  from  school  because  he  was  unmanageable  and  had 
a  baneful  influence  on  his  fellow-students  ?  Much  assistance 
can  be  obtained  from  the  history,  and  it  is  valuable  when 
the  conduct  which  has  given  rise  to  a  suspicion  of  mental 
disorder  comes  to  be  considered. 

If  the  charge  is  that  of  stealing,  there  is  a  difference  to 
be  discovered  between  the  thieving  of  the  purely  vicious 
and  the  pilfering  of  the  moral  delinquent.  Motive  they  may 
both  have,  though  the  truly  morally  insane  individual  will 
incur  grave  risks  of  punishment  and  disgrace  for  the  grati- 


MORAL  IMBECILITY  367 

fication  of  taking  some  very  trifling  object.  The  vicious  man 
hides  his  spoil ;  the  other  either  leaves  it  lying  about  for 
all  to  see,  or  puts  it  in  some  drawer  or  box,  unprotected  by 
lock  and  key,  and  open  to  the  inspection  of  any  chance  comer. 
Though  cunning  and  deceitful  in  his  methods,  the  morally 
insane  person  is  almost  childish  in  his  ingenuousness  and  "v^dll 
show  his  ill-gotten  gains  to  anyone,  whether  friend  or  foe. 

There  is  no  doubt  that  the  majoritj^  of  persons  for  whom 
the  plea  of  kleptomania  is  advanced  when  they  are  charged 
with  stealing  are  in  reality  accomplished  thieves,  and  have 
no  claim  to  be  sheltered  from  the  penalties  of  their  wrong- 
doing. This  being  the  case,  it  should  make  us  all  the  more 
alert  that  persons  deserving  of  protection  should  not  be 
allowed  to  be  swept  in  among  the  common  herd  of  criminals. 
In  brief,  it  is  largely  the  conduct  that  is  affected  in  moral 
imbeciles.  In  conversation  they  may  be  bright  and  intellectual, 
and  perfectly  capable  of  defending  thek  actions  by  extravagant 
falsehoods  ;  but  the  conduct  is  defective,  and  has  probably 
been  defective  from  childhood. 

The  offences  they  commit  vary  in  gravity,  but  as  a  rule 
the  punishment  they  risk  incmiing  is  out  of  all  proportion  to 
the  advantages  gained.  A  boy  will  set  fire  to  a  house  either 
for  the  pleasure  of  seeing  it  burn,  or  to  pay  off  some  old  score 
against  a  master,  or  to  punish  some  person  who  has  annoyed 
him.  Again,  the  manner  in  which  the  deed  is  done  frequently 
mirrors  the  mental  state  of  the  delinquent.  A  girl  will  make 
a  series  of  false  accusations  against  a  man  and  wiU  endeavour 
to  support  them  by  some  method  devised  by  herself.  A  woman 
has  been  known  to  write  libellous  postcards  to  a  man  at  his 
club,  and  in  order  to  avoid  suspicion  she  has  from  time  to  time 
addressed  an  abusive  missive  to  herself. 

Many  are  the  difficulties  and  deep  the  pitfalls  that  lie  in 
the  path  of  him  who  has  to  decide  whether  a  man  is  a 
ci'iminal  or  morally  insane.  The  line  of  demarcation  between 
the  criminal  and  the  morally  insane  is  necessarily  slight.  Viewed 
from  the  standpoint  of  a  law-abiding  subject,  the  criminal 
must  be  akin  to  the  insane,  in  that  to  a  normal  mind  the 
average  profits  of  a  career  of  crime  bear  no  sound  proportion 
to  the  price  at  which  those  profits  are  earned.  Nor  can  there 
be  any  doubt  that  this  common-sense  aspect  of  the  matter 


368  PSYCHOLOGICAL  MEDICINE 

has  a  foundation  in  scientific  fact.  The  majority  of  criminals 
are  degeneratives,  and  many  present  abnormal  mental  char- 
acteristics. The  argument  pressed  to  a  logical  conclusion 
might  go  to  show  that  crime  is  symptomatic  of  insanity, 
evidencing  as  it  does  a  lack  of  sense  of  proportion  and  of  true 
mental  balance.  Here,  however,  the  term  '  moral  imbecility  ' 
is  applied  only  to  those  who  are  born  deficient  in  a  quality  or 
attribute,  and  not  to  those  who  have  lost  that  quality  or 
attribute,  or  in  whom  it  has  become  obliterated  by  conscious 
vice  or  by  their  environment.  The  difficulty  of  distinguishing 
between  the  two  classes  is  great.  Each  case  must  be  judged 
impartially  and  on  its  own  merits,  after  the  physician  has 
conscientiously  weighed  the  evidence  which  he  has  been 
able  to  collect. 

Prognosis. — The  prognosis  is  not  good,  and  the  tendency  is 
for  the  patient  to  become  more  and  more  difficult  to  manage 
with  increasing  years.  There  are  no  recoveries,  as  the  condi- 
tion is  due  to  a  deficiency  in  the  mental  requirements  to  which 
neither  time  nor  skill  can  add.  The  best  result  that  can  be 
hoped  for  is  that  with  careful  supervision  the  patient  can  be 
managed  in  his  own  house. 

Treatment.— The  prophylactic  treatment  lies  in  the  pre- 
vention of  marriage  of  degenerate  persons.  Early  and  wise 
education  can  assist  in  a  few  cases,  but  the  majority  of  the 
children  require  very  special  training.  It  is  useless  to  send 
them  to  ordinary  schools,  as  before  many  months  are  past 
they  will  probably  be  expelled  in  disgrace.  They  should  be 
sent  to  special  schools,  where  their  vicious  tendencies  are 
understood,  and  where,  in  the  event  of  their  failing  to  acquire 
a  knowledge  of  the  moral  laws  which  rule  society,  they  will  be 
prevented  from  committing  any  serious  offence.  These  cases 
can  now  be  certified  under  the  Mental  Deficiency  Act,  as  below 
given  : 

1.  The  following  classes  of  persons  shall  be  deemed  to  be 
defectives  within  the  meaning  of  the  Mental  Deficiency  Act, 
1913  :— 

(a)  Idiots  ;    that  is  to  say,  persons  so  deeply  defective  in 

mind  from  birth  or  from  an  early  age  as  to  be  unable  to 
guard  themselves  against  common  physical  dangers  : 

(b)  Imbeciles  ;  that  is  to  say,  persons  in  whose  case  there 


MORAL  IMBECILITY  369 

exists  from  birth  or  from  an  early  age  mental  defec- 
tiveness not  amounting  to  idiocy,  yet  so  pronounced 
that  they  are  incapable  of  managing  themselves  or 
their  affairs,  or,  in  the  case  of  children,  of  being  taught 
to  do  so. 
(c)  Feeble-minded  persons  ;   that  is  to  say,  persons  in  whose 
case  there  exists  from  birth  or  from  an  early  age 
mental  defectiveness   not  amounting   to  imbecility, 
yet  so  pronounced  that  they  require  care,  supervision, 
and  control,  for  their  own  protection  or  for  the  pro- 
tection of  others,  or,  in  the  case  of  children,  that 
they  by  reason  of  such  defectiveness  appear  to  be 
permanently  incapable  of    receiving  proper   benefit 
from  the  instruction  in  ordinary  schools, 
{d)  Moral  imbeciles  ;    that  is  to  say,  persons  who  from  an 
early    age    display   some   permanent    mental    defect 
coupled  with  strong  vicious  or  criminal  propensities  on 
which  punishment  has  had  Httle  or  no  deterrent  effect. 
II.  (1)  A  person  who  is  a  defective  may  be  dealt  with  under 
this  Act  by  being  sent  to  or  placed  in  an  institution  for  de- 
fectives or  placed  under  guardianship — - 

(a)  at  the  instance  of   his  parent  or  guardian  if  he  is  an 
idiot  or  imbecile,  or  at  the  instance  of  his  parent,  if, 
though  not  an  idiot  or  imbecile,  he  is  under  the  age 
of  twenty-one  ;  or 
{b)  if  in  addition  to  being  a  defective  he  is  a  person — ■ 

(i)  who  is   found  neglected,  abandoned,  or  without 

visible  means  of  support,  or  cruelly  treated ;  or 
(ii)  who  is  found  guilty  of  any  criminal  offence,  or 
who  is  ordered  or  found  liable  to  be  ordered  to  be 
sent  to  a  certified  industrial  school ;  or 
(iii)   who   is   undergoing  imprisonment    (except   im- 
prisonment under  civil  process),  or  penal  servitude, 
or  is  undergoing  detention  in  a  place  of  detention 
by  order  of  a  court,  or  in  a  reformatory  or  industrial 
school,  or  in  an  inebriate  reformatory  or  who  is 
detained  in  an  institution  for  lunatics  or  a  criminal 
lunatic  asylum ;  or 
(iv)  who  is  an  habitual  drunkard  within  the  meaning 
of  the  Inebriates  Acts  1879  to  1900  ;  or 

24 


370  PSYCHOLOGICAL  MEDICINE 

(v)  in  whose  case  such  notice  has  been  given  by  the 
local  education  authority  as  is  hereinafter  in  this 
section  mentioned  ;  or 
(vi)  who  is  in  receipt  of  poor  rehef  at  the  time  of  giving 
birth  to  an  illegitimate  child  or  when  pregnant  of 
such  child. 
(2)  Notice  shall,  subject  to  regulations  made  by  the  Board 
of   Education,    to   be   laid   before   Parliament   as   hereinafter 
provided,  be  given  by  the  local  education  authority  to  the 
local  authority  under  this  Act  in  the  case  of  all  defective 
children  over  the  age  of  seven — 

(a)  who   have  been   ascertained  to  be  incapable  by  reason 
of  mental  defect  of  receiving  benefit  or  further  benefit 
in  special  schools  or  classes,  or,who  cannot  be  instructed 
in  a  special  school  or  class  without  detriment  to  the 
interests  of  the  other  children,  or  as  respects  whom  the 
Board  of  Education  certify  that  there  are  special  cir- 
cumstances which  render  it  desirable  that  they  should 
be  dealt  with  under  this  Act  by  way  of  supervision 
or  guardianship  ; 
(6)  who  on  or  before  attaining  the  age  of  sixteen  are  about 
to  be  withdrawn  or  discharged  from  a  special  school 
or    class,    and    in    whose   case   the    local   education 
authority  are  of  opinion  that  it  would  be  to  their 
benefit  that  they  should  be  sent  to  an  institution  or 
placed  under  guardianship. 
III.  (1)  The  parent  or  guardian  of  a  defective  who  is  an 
idiot  or  imbecile,  and  the  parent  of  a  defective  who  though  not 
an  idiot  or  imbecile  is  under  the  age  of  twenty-one,  may  place 
him  in  an  institution  or  under  guardianship.     Provided  that 
he  shall  not  be  so  placed  in  an  institution  or  under  guardianship, 
except  upon  certificates  in  the  prescribed  form  signed  by  two 
duly  qualified  medical  practitioners,  one  of  whom  shall  be  a 
medical  practitioner  approved  for  the  purpose  by  the  local 
authority  or  the  Board,  and,  where  the  defective  is  not  an 
idiot  or  imbecile  also  signed,  after  such  enquiry  as  he  shall 
think  fit,  by  a  judicial  authority  for  the  purposes  of  this  Act, 
stating  that   the  signatories  of  the  certificate  are  severally 
satisfied  that  the  person  to  whom  the  certificate  relates  is  a 
defective  and  the  class  of    defectives  to  which    he   belongs. 


MORAL  IMBECILITY  371 

accompanied  by  a  statement,  signed  by  the  parent  or  guardian, 
giving  the  prescribed  particulars  with  respect  to  him. 

(2)  Where  a  defective  has  been  so  placed  in  an  institution 
for  defectives  or  under  guardianship,  the  managers  of  the 
institution,  or  the  person  under  whose  guardianship  he  has  been 
placed,  shall,  within  seven  days  after  his  reception,  send  to  the 
Board  of  Control  hereinafter  constituted  (in  this  Act  referred  to 
as  the  Board)  notice  of  his  reception  and  such  other  particulars 
as  may  be  prescribed. 

IV.  A  defective  subject  to  be  dealt  with  under  this  Act  other- 
wise than  under  paragraph  (A)  of  sub-section  (1)  of  section  U 
of  this  Act  may  so  be  dealt  with — 

(A)  under  an  order  made  by  a  judicial  authority  on  a  petition 

presented  under  this  Act ;   or 

(B)  under  an  order  of  a  court  in  the  case  of  a  defective  found 

guilty  of  a  criminal  offence,  punishable  in  the  case  of 
an  adult  with  imprisonment  or  penal  servitude,  or  liable 
to  be  ordered  to  be  sent  to  an  industrial  school ;   or 

(C)  under  an  order  of  the  Secretary  of  State,  in  the  case  of 

a  defective  detained  in  a  prison,  criminal  lunatic 
asylum,  reformatory  or  industrial  school,  place  of 
detention  or  inebriate  reformatory  ; 

but  no  such  order  shall  be  made  except  in  the  circumstances  and 

in  the  manner  hereinafter  specified. 

Eequikembnts  as  to  the  making  of  Orders 

V.  (1)  An  order  of  a  judicial  authority  under  this  Act  shall 
be  obtainable  upon  a  private  application  by  petition  made  by 
any  relative  or  friend  of  the  alleged  defective,  or  by  any  officer 
of  the  local  authority  under  this  Act  authorised  in  that 
behalf. 

(2)  Every  petition  shall  be  accompanied  by  two  medical 
certificates,  one  of  which  shall  be  signed  by  a  medical  practi- 
tioner approved  for  the  purpose  by  the  local  authority  or  the 
Board,  or  a  certificate  that  a  medical  examination  was  imprac- 
ticable, and  by  a  statutory  declaration  made  by  the  petitioner 
and  by  at  least  one  other  person  (who  may  be  one  of  the  persons 
who  gave  a  medical  certificate)  stating — 

(A)  that  the  person  to  whom  the  petition  relates  is  a  defective 


372  PSYCHOLOGICAL  MEDICINE 

within  the  meaning  of  this  Act,  and  the  class  of  de- 
fectives to  which  he  is  alleged  to  belong  ;  and 

(B)  that  that  person  is  subject  to  be  dealt  with  under  this 

Act,  and  the  circumstances  which  render  him  so 
subject ;  and 

(C)  whether  or  not  a  petition  under  this  Act,  or.  a  petition 

for  a  reception  order  under  the  Lunacy  Acts,  1890- 
1911,  has  previously  been  presented  concerning  that 
person,  and  if  such  a  petition  has  been  presented,  the 
date  thereof  and  the  result  of  the  proceedings 
thereon  ;   and 

(D)  if  the  petition  is  accompanied  by  a  certificate  that  a 

medical  examination  was  impracticable,  the  circum- 
stance which  rendered  it  impracticable. 

(3)  If  a  petition  is  not  presented  by  a  relative  or  by  an  officer 
of  the  local  authority,  it  shall  contain  a  statement  of  the 
reasons  why  the  petition  is  not  presented  by  a  relative,  and  of 
the  connection  of  the  petitioner  with  the  person  to  whom  the 
petition  relates  and  the  circumstances  under  which  he  presents 
the  petition. 

(4)  Where  the  Board  are  satisfied  that  a  petition  under  this 
section  ought  to  be  presented  concerning  any  person,  and  that 
the  local  authority  have  refused  or  neglected  to  cause  a  petition 
to  be  presented,  they  may  direct  an  inspector  or  other  officer 
to  present  a  petition,  and  this  section  shall  apply  accordingly. 


373 


CHAPTEE  XXI 

FEIGNED    INSANITY 

In  every  branch  of  medicine  and  surgery  the  medical  man 
may  suddenly  be  called  upon  to  decide  whether  in  a  given 
case  the  disease  complained  of  is  real  or  assumed.  Mental 
disorder  seems  to  be  a  favourite  malady  to  feign,  and  no  doubt, 
to  the  unskilled,  insanity  appears  to  lend  itself  more  readily 
to  deception  than  almost  any  other  disease.  The  persons  who 
are  most  likely  to  resort  to  malingering  are  criminals  who  are 
awaiting  trial  for  some  grave  offence,  or  men  desirous  of 
escaping  from  one  of  the  public  services.  Our  military  and 
naval  surgeons  are  constantly  encountering  these  persons, 
and  it  frequently  requires  the  greatest  tact  and  acumen  to 
diagnose  these  cases  successfully.  But  the  feigning  of 
insanity  is  by  no  means  confined  to  the  Army  and  Navy, 
and  most  medical  men  in  general  practice  from  time  to  time 
meet  with  these  malingerers.  Physicians  connected  with 
railways,  insurance  companies,  or  benefit  clubs  are  especially 
exposed  to  imposition  of  this  kind,  and  even  the  general 
practitioner  in  his  daily  rounds  may  meet  with  it  among  his 
private  patients. 

No  doubt  in  the  great  majority  of  cases  there  is  some  good 
motive  for  assuming  disease,  but  this  is  not  always  true  ;  and 
sometimes  the  motive  is  not  apparent  to  the  casual  observer. 
Too  much  importance  must  not  be  attached  to  motive,  other- 
wise there  is  a  danger  of  being  misled,  for  what  might  be  con- 
sidered by  one  person  as  sufficient  reason  for  a  certain  action 
another  might  consider  totally  inadequate.  The  time  of  onset 
of  the  supposed  insanity  is  a  fact  to  be  recorded.  It  is  rare 
indeed  for  a  man  to  simulate  mental  disease  in  order  to  avoid 
the  suspicion  of  being  connected  with  some  crime.  Mental 
aberration,  if  resorted  to  by  the  criminal,  is  not  assumed  until 


374  PSYCHOLOGICAL  MEDICINE 

a  charge  has  definitely  been  laid.  Therefore  care  must  be 
exercised  in  collecting  the  data  of  the  individual's  conduct  and 
conversation  for  some  time  previous  to  the  crime  in  question. 
If  he  has  already  suffered  from  attacks  of  insanity  earlier  in 
life  it  may  be  possible  for  mental  disease  to  reappear  some- 
what suddenly,  but  otherwise  it  must  be  remembered  that, 
save  under  exceptional  circumstances,  the  rapid  develop- 
ment of  insanity  is  not  common. 

This  suggests  the  next  point  for  investigation,  viz.  the 
mode  of  onset  of  the  illness.  Has  it  begun  in  the  usual  way 
with  sleeplessness  and  maybe  a  feeling  of  malaise  ?  Was 
the  man  irritable,  inattentive,  and  restless  for  some  time  before 
the  more  serious  symptoms  of  mental  disorder  declared  them- 
selves ?  Wliat  is  the  family  history  of  the  individual  ?  Does 
he  inherit  mental  instability  ?  Were  his  parents  or  immediate 
relations  ever  insane  or  subject  to  epilepsy  or  kindred  diseases  ? 
The  family  history  is  not  always  obtainable,  except  maybe 
from  the  patient  himself  ;  and  although  definite  proof  of  an 
unstable  inheritance  is  an  important  factor  in  the  consideration 
of  a  case,  absence  of  any  such  evidence  does  not  permit  us  to 
form  any  conclusion.  Endeavour,  if  possible,  to  obtain  a  full 
account  of  the  life-history  of  the  patient  ;  make  a  record  of 
the  illnesses  he  has  had,  any  known  peculiarities  of  disposition, 
and  whether  he  is  noted  for  his  sobriety  or  the  reverse. 

After  these  prefatory  inquiries  the  immediate  symptoms 
of  the  supposed  disease  should  be  examined.  The  student 
nmst,  as  has  been  before  observed,  remember  that  in  a  vast 
majority  of  cases  of  mental  disorder  the  physical  health  is  also 
affected.  In  some  types  of  insanity  the  bodily  health  suffers 
severely,  whereas  in  others  the  disturbances  are  less  marked. 
This  knowledge  is  very  valuable  when  a  decision  has  to  be  made 
as  to  whether  the  disease  is  true  or  spurious.  Endeavour  to 
find  out  whether  there  is  any  apparent  cause,  mental  or  physi- 
cal, for  a  mental  break-do^vn.  Persistent  refusal  of  food  rather 
favours  true  insanity,  for  the  simulator  rarely  permits  himself 
to  be  fed  by  means  of  an  oesophageal  or  nasal  tube.  Quanti- 
tative incoherence  is  almost  impossible  in  a  sane  person,  and 
if  this  symptom  is  present,  there  can  bo  but  little  doubt  as  to 
the  diagnosis  being  that  of  true  insanity.  If  the  reader  ques- 
tions this  statement,  let  him  try  to  be  incoherent  for  three 


FEIGNED  INSANITY  375 

consecutive  minutes.  During  this  time  he  will  probably  con- 
stantly repeat  the  same  words,  neither  will  he  be  incoherent 
the  whole  time.  A  sane  man  may  wander  in  his  conversation 
and  may  stray  from  subject  to  subject ;  but  he  is  usually  readily 
followed  by  his  audience.  There  is  a  vast  difference  between 
desultory  conversation  and  true  incoherence.  When  a  stranger 
visits  a  person  of  unsound  mind,  the  latter  commonly  appears 
to  be  much  better  mentally  than  he  really  is,  as  for  the 
moment  his  attention  is  arrested  or  he  is  on  his  guard.  This 
characteristic  is  a  very  important  one  and  can  be  tested  by 
anyone  who  visits  an  asylum.  It  is  owing  to  this  peculiarity 
that  so  many  casual  observers  overlook  insanity  and  pronounce 
a  man  to  be  sane  when  in  truth  he  is  suffering  from  profomid 
mental  disorder.  The  visiting  magistrate  is  frequently  misled, 
unless  he  has  learnt  by  experience  that  this  pitfall  lies  in  his 
way  and  reahses  that  fairly  to  examine  a  man's  mental  state  it 
is  necessary  to  probe  somewhat  deeper  and  not  merely  accept 
what  appears  on  the  surface.  But  how  is  it  with  the  maUngerer — 
is  he  willing  to  appear  better  than  he  really  is  ?  By  no  means  ; 
he  is  already  9,fraid  that  he  may  not  be  judged  to  be  insane,  and 
he  feels  that  he  must  run  no  risks.  The  advent  of  a  stranger 
usually  heralds  the  appearance  of  all  symptoms,  and  the  patient, 
so  far  from  seeming  to  be  better,  is  much  more  energetically 
insane  than  when  alone. 

Further,  most  insane  individuals  declare  themselves  to  be 
sane  and  disagree  with  anyone  who  even  suggests  that  they 
are  suffering  from  any  form  of  mental  disorder.  The  insane 
man  will  account  for  his  altered  thoughts  and  feelings  in 
numberless  ways,  but  he  will  rarely,  if  ever,  assent  to  being 
considered  of  unsound  mind.  The  malingerer  is  the  very 
antithesis  of  this  ;  he  never  asserts  his  sanity,  unless  it  be  in 
some  half-hearted  way.  He  wishes  to  be  pronounced  insane 
and  will  not  make  any  suggestions  which  might  cause  the 
physician  to  come  to  any  other  conclusion.  It  will  often  prove 
-of  the  utmost  value  in  determining  whether  insanity  be  true 
or  feigned  to  remember  this  point.  The  simulator  is  rarely 
content  to  be  passive  while  the  question  of  his  mental  state  is 
being  weighed,  and  commonly  his  energies  are  directed  to 
producing  convincing  proof  of  his  insanity.  He  is  often 
noisy,  or  will  fling  himself  about  the  room  in  an  extravagant 


376         '  rSYCHOLOGICAL  MEDICINE 

frenzy,  when  visited  by  strangers  ;  and  yet  when  alone  he 
is  quiet  and  well-behaved.  Tliis  over-acting  is  very  charac- 
teristic of  the  maHngerer  ;  he  finds  the  strain  of  simulating 
insanitj^  a  severe  one,  and  accordingly  prefers  to  use  his  powers 
when  visitors  are  present  rather  than  when  alone. 

Another  marked  distinction  between  true  and  feigned 
insanity  is  that  the  truly  insane  are  consistent,  while  the 
sane  feigning  insanity  are  more  commonly  inconsistent.  The 
sane  man  has  to  be  constantly  adapting  himself  to  his  sur- 
roundings, which  are  for  ever  changing.  He  says  that  he 
will  do  something,  but  does  the  reverse,  because  he  finds  that 
circumstances  have  altered.  An  insane  person  is  more  con- 
sistent than  this,  and  if  he  decides  to  do  a  certain  thing,  he 
will  usually  carry  it  through  in  spite  of  its  proving  disagree- 
able or  distressing. 

Convictions  are  often  stronger  in  the  mentally  unstable  ; 
for  the  sounder  mind  is  constantly  weighing  considerations 
for  and  against  the  advisabihty  of  any  particular  act  and  is 
more  ready  to  abandon  a  previously  declared  determination. 
This  question  of  consist enc}^  is  important  when,  examining  a 
person  for  feigned  insanit3\  The  conduct  of  the  insane  is 
usually  in  keeping  with  their  conversation.  If  a  man  truly 
insane  talks  extravagant^,  his  conduct  is  correspondingly 
prodigal ;  or  if  his  speech  is  the  expression  of  melanchoKc 
thoughts,  his  attitudes  will  reflect  the  depression  of  his 
mind. 

It  happens  sometimes  in  cases  of  real  msanity  that  the 
patient  is  far  more  insane  in  his  actions  than  in  his  conver- 
sation, for  he  may  be  guarded  in  the  latter.  With  the  mahn- 
gerer  the  reverse  is  not  imcommonly  observed,  for  the  man 
who  feigns  disease  at  times  forgets  that  he  is  acting  a  part, 
or,  in  giving  gi-eat  attention  to  that  phase  of  the  part  wliich 
hes  in  speech,  loses  sight  of  the  phase  which  hes  in  conduct 
and  so  betrays  h'mself.  When  a  man  refuses  to  speak,  in- 
formation as  to  his  true  mental  state  can  only  be  derived 
from  a  study  of  his  behaviour.  We  know  the  diseases  in  which 
mutism  occurs,  and  we  must  examine  the  individual  for  the 
symptoms  common  to  these  maladies.  If  the  refusal  to  speak 
appears  to  be  due  to  some  delusion,  it  may  become  necessary 
to   place  the  patient   under  constant   observation   for   some 


FEIGNED  INSANITY  377 

time.     Under  such  supervision  he  may  be  caught  in  an  unwary 
mood,  or  he  may  become  weary  of  his  self-inflicted  task. 

A  clumsy  actor  may  assume  too  profound  weak-minded- 
ness, and  with  care  his  deceit  may  be  discovered.  Test  the 
malingerer  by  some  simple  method,  such  as  inviting  him  to 
name  coins  or  some  common  articles  of  daily  use.  He  may, 
from  excess  of  caution  and  in  the  fear  of  showing  sanity  by 
correct  answers,  name  the  objects  wrongly.  A  truly  insane 
person  would  probably  be  insulted  or  smile  when  requested  to 
do  such  a  childish  thing  and  might  ask  you  if  you  took  him 
for  a  fool ;  nevertheless  he  would  answer  correctly  unless 
intensely  excited.  Sleeplessness  is  a  sj-mptom  which  cannot 
be  simulated  for  long  ;  the  malingerer  may  keep  himself  awake 
for  a  night  or  two,  but  sooner  or  later  he  is  overcome  by  the 
exhaustion  of  his  self-imposed  effort  and  sleeps  soundly. 
Now  in  nearly  all  forms  of  acute  insanity  insomnia  is  a  promi- 
nent sj^mptom,  and  a  certain  amount  of  suspicion  may  fairly 
be  entertained  where  sound  sleep  accompanies  a  recent  develop- 
ment of  apparently  acute  mental  disturbance.  This  mistrust 
w^ould  be  accentuated  if  supported  by  any  other  inconsistent 
phenomena. 

Delusions  might  be  supposed  to  be  easily  simulated,  but 
this  is  by  no  means  the  case.  Many  of  the  truly  insane  are 
very  reticent  about  their  beliefs  and  disbeliefs,  and  it  is  often 
only  by  observation  of  their  eccentric  conduct  that  their  ideas 
can  be  discovered.  The  insane  man  declares  himself  in  a 
hundred  little  ways,  but  always  has  an  explanation  ready  for 
any  criticism  of  his  actions  and  will  at  once  stoutly  deny 
any  suggestion  that  his  mind  is  unhinged.  The  malingerer 
frequently  limits  himself  to  one  or  two  delusions  which  he 
constantly  harps  upon,  but  he  will  often  prove  himself  a  cheat 
in  that  his  actions  are  not  always  in  keeping  with  his  ex- 
pressed beliefs.  Hallucinations  and  illusions  should  be  tested, 
and  although  the  reality  of  them  may  be  difficult  to  disprove, 
nevertheless  it  may  be  possible  to  discover  the  fraud.  Some 
authorities  lay  stress  on  a  peculiar  attentive  watchfulness 
wdiicli  they  consider  to  be  a  characteristic  of  the  malingerer  ; 
but  care  must  be  taken  not  to  confound  such  a  symptom  with 
the  guarded  manner  of  a  genuinely  insane  person  in  the  presence 
of  strangers. 


378  PSYCHOLOGICAL  MEDICINE 

With  regard  to  the  forms  of  mental  disorder  chosen  by- 
impostors,  they  will  be  found  to  be  very  varied.  True  melan- 
cholia develops  gradually,  the  symptoms  always  being  more 
marked  in  the  early  morning  ;  further,  the  physical  health 
suffers,  and  the  patient  is  sleepless.  Altogether  the  con- 
dition is  not  an  easy  one  to  feign  with  any  degree  of  success. 
Simple  melancholia  and  the  subacute  types  of  depression 
could  be  simulated  more  easily,  but  they  are  seldom  chosen, 
as  the  malingerer  fears  that  with  so  mild  a  mental  disturb- 
ance he  would  not  be  deemed  to  be  insane.  No  one  but 
the  boldest  or  most  unskilled  of  impostors  would  dare  to 
choose  acute  mania  for  his  deception.  The  malingerer  fails  at 
the  very  outset,  as  incoherence  is  beyond  his  powers.  The 
acute  maniac  is  continually  on  the  move  day  and  night  ;  he 
rarely  sleeps  ;  he  is  capricious  with  his  food.  The  impostor 
mostly  over-acts  his  part  when  in  the  presence  of  others  and 
under-acts  it  when  alone  ;  after  a  few  hours  of  feigned  excite- 
ment he  wearies  and  sleeps.  He  further  differs  from  the  truly 
maniacal  person  in  that  it  is  usually  impossible  to  get  his  atten- 
tion even  for  one  brief  moment. 

Some  persons  select  delusional  insanity  for  their  fraud. 
Here  the  physician  must  remember  that  delusional  states  are 
usually  of  slow  development ;  step  by  step  the  patient  weaves 
his  story  ;  and  in  the  early  weeks  of  the  disorder  his  want  of 
mental  balance  is  commonly  shown  by  his  erratic  conduct 
rather  than  by  his  extravagant  conversation.  The  man  be- 
lieves that  he  is  the  victim  of  some  conspiracy  and  is  for 
ever  watching  for  some  corroborative  evidence  to  support 
his  belief  ;  in  a  thousand  ways  he  shows  his  suspicions,  and 
yet  rarely,  if  ever,  expresses  his  thoughts  in  words.  The 
impostor  will  develop  an  organised  delusion  in  a  day  and 
will  exhaust  his  hearers  by  constantly  repeating  in  almost  the 
same  words  his  false  beliefs.  The  malingerer  fails  to  keep 
his  actions  always  in  harmony  with  his  supposed  delusions, 
and  his  want  of  consistency  is  very  helpful  in  exposing 
the  imposture. 

Profound  dementia  is  another  form  of  insanity  that  is 
sometimes  chosen,  but  in  this  again  the  malingerer  very 
readily  falls  into  an  evident  error.  He  is  apt  to  assume  a 
sudden  mental  enfeelilement  of  a  very  advanced  type.  Now, 
we   know   thai    dementia    usually  runs  a  steady  progressive 


FEIGNED  INSANITY  379 

course  ;  gradually  over  an  extended  period  of  months  mental 
dissolution  takes  place  ;  the  attributes  of  later  development 
fail  and  are  followed  in  time  by  those  which  are  more  organised. 
Dementia  is  nearly  always  secondary  to  some  acute  attack 
of  mental  disease,  except  in  such  instances  as  alcoholism  or 
senility,  and  even  then  its  course  is  not  a  rapid  one. 

In  conclusion,  we  should  add  that  in  all  cases  of  doubt 
the  individual  should  be  placed  under  constant  supervision, 
and  a  careful  record  of  his  conduct  should  be  kept  both  by 
day  and  night.  Avoid  forming  too  rapid  a  judgment,  as  a 
great  injustice  may  be  done  by  too  readily  concluding  that  a 
man  is  an  impostor.  The  unskilled  malingerer  is  easily  de- 
tected. His  ideas  of  insanity  are  crude  and  resemble  the 
insanity  so  commonly  depicted  on  the  stage,  which  has  the 
sanction  of  tradition  rather  than  of  truth.  The  expert  im- 
postor is  the  man  who  gives  the  physician  the  real  difficulty  ; 
but  his  deception  is  not  unfathomable,  and  thoroughness  and 
watchfulness  will  slowly  but  surely  expose  the  fraud.  It  takes 
time,  but  the  malingerer  will  lose  confidence  in  himself  when 
once  he  sees  that  he  is  playing  a  losing  game. 

Treatment. — The  treatment  of  malingering  calls  for  many 
of  the  highest  qualities  with  which  a  physician  can  be  gifted. 
To  begin  with,  the  patient  must  have  no  idea  of  the  suspicions 
of  his  medical  attendant,  and  no  suggestion  of  the  possibility 
of  fraud  should  be  confided  to  the  nurse.  To  tell  her  that 
you  believe  the  man  to  be  a  malingerer  is  one  of  the  surest 
ways  of  defeating  the  end  in  view.  Carefully  give  your  in- 
structions as  to  the  symptoms  you  require  to  be  watched  and 
note  down  any  information  that  the  nurse  may  volunteer, 
but  receive  everything  without  comment.  When  the  patient 
converses  with  you,  keep  an  impassive  expression  and  manner. 
After  a  time  a  casual  suggestion  in  his  presence  as  to  your 
surprise  at  the  absence  of  certain  symptoms  may  induce  him 
to  add  them  to  those  which  he  has  already  assumed.  A  quiet 
acknowledgment  of  such  additions  may  encourage  him  to 
accept  from  time  to  time  any  other  suggestions  that  you  may 
choose  to  make.  When  you  have  definitely  concluded  that  you 
are  dealing  with  an  impostor,  it  is  frequently  wise  to  let  the 
patient  see  that  you  fully  realise  the  true  condition.  Kigid 
treatment  with  exceptionally  plain  diet  not  uncommonly  tends 
to  bring  about  a  rapid  recovery. 


380  PSYCHOLOGICAL  MEDICINE 


CHAPTEE  XXII 

THE   RELATIONSHIP    OF  INSANITY    WITH    LAW 

This  subject  is  not  only  of  intense  interest  to  medical  men 
but  is  of  no  small  importance  to  those  who  are  connected 
with  the  administration  of  the  law.  The  responsibilities  of 
the  insane,  whether  they  be  civil  or  criminal,  are  a  matter 
of  much  concern  to  the  community  at  large.  The  question 
of  how  far  an  insane  person  can  be  held  responsible  for  a 
crime  is  a  question  which  has  constantly  to  be  decided  in  our 
courts  of  justice.  We  must  not  forget  that  in  some  cases  of 
mental  disease,  where  disorders  of  conduct  are  the  chief  charac- 
teristic, the  dividing  line  between  insanity  and  crime  is  by  no 
means  easy  to  detect.  Perhaps  there  is  the  greatest  difficulty 
in  those  cases  of  moral  insanity  in  which  the  mental  aberration 
is  shown  by  inability  on  the  part  of  the  individual  to  conform 
to  the  moral  code  of  laws  laid  down  by  society  ;  in  such  cases 
the  line  of  demarcation  between  responsibility  and  disease 
becomes  very  fine  indeed.  It  is  in  dealing  with  these  border- 
land cases  of  insanity  that  the  medical  and  legal  professions 
have  so  many  disagreements. 

The  legal  and  medical  sciences  are  antipathetic  in  two 
essential  respects,  their  objects  and  their  natures.  The  good 
of  society  is  the  first  object  of  the  law  ;  its  nature  is  to  be 
definite.  The  good  of  the  individual  is  the  first  object  of 
medicine  ;  its  nature,  as  with  all  progressive  sciences,  is  to  be 
tentative.  Incidentally  the  medical  science  benefits  society, 
but  it  does  so  through  the  individual.  Incidentally  law  bene- 
fits an  individual  by  conferring  upon  him  the  advantage  of 
security.  It  is  in  attaining  their  primary  objects  that  both 
law  and  medicine  may  err  ;  law  by  unduly  punishing  the 
individual  for  the  general  good,  medicine  by  fostering  the 
individual  claim  at  the  expense  of  society  as  a  whole.     To 


THE  RELATIONSHIP  OF  INSANITY  WITH  LAW  381 

a  lawyer,  society  has  claims  so  paramount  as  to  demand  recog- 
nition even  at  the  cost  of  wrong  to  the  individual.  To  the 
medical  practitioner  the  advantage  to  society  is  obscured  by 
his  lively  appreciation  that  wi'ong  is  being  done  to  his  patient 
who  is  his  first  concern. 

The  difference  in  the  natui-e  of  the  two  sciences  is  not  less 
marked.  Law  is  not  and  cannot  usefully  be  too  elastic.  It 
is  of  social  urgency  that  the  responsibility  of  the  individual 
should  be  well  defined.  Precision  is  uppermost  in  the  mind 
of  those  who  make  and  of  those  who  administer  the  law. 
Medical  science  is  essentially  progressive  and  shrinks  from 
positive  assertion.  The  accepted  medical  truth  of  yesterday 
is  perhaps  doubted  to-day  and  may  be  denounced  as  a  plain 
falsehood  to-m^orrow.  Experience  has  taught  the  exponent 
of  the  medical  as  of  every  progressive  science  the  lesson  of 
caution  in  assertion.  He  knows  he  is  still  learning,  and  he 
knows  there  are  many  things  he  has  yet  to  learn.  Especially 
must  this  be  the  case  when  he  is  dealing  with  questions  so 
delicate  as  those  which  at  every  point  confront  one  whose 
study  is  the  brain,  the  nervous  system,  and  their  disorders. 

It  is  these  cardinal  differences  that  bring  the  professions 
of  law  and  medicine  into  conflict.  The  lawyer  must  have  his 
facts  and  must  discard  evidence  that  does  not  lead  to  an 
irresistible  inference  of  fact.  The  medical  man  frequently 
finds  himself  so  placed  that,  while  unable  to  assert  that  a 
thing  is  so,  he  dare  not  say  that  it  is  not  so.  The  law  says 
that  there  is  a  presumption  that  every  man  is  sane,  and  that 
the  burden  of  proving  that  he  is  not  lies  upon  the  person  who 
alleges  insanity.  The  physician  appreciates  what  unstable 
inheritance  or  moral  degeneration  means  and  founds  his  case 
upon  it.  It  is  too  flimsy  a  fabric  for  the  lawyer  with  a  craving 
for  iiTesistible  inferences.  The  individual  must  suffer.  The 
fault  is,  however,  not  all  on  one  side.  The  physician  knows 
that  a  man's  constitution  bears  upon  it  the  stamp  of  his  fore- 
fathers, and  that,  as  Maudsley  tersely  puts  it,  he  may  '  suffer 
fi'om  the  tyranny  of  his  organisation.' 

In  approaching  his  cases  the  physician  is  therefore  apt  to 
take  too  generous  a  view  of  conduct  and  to  lend  the  weight 
of  his  opinion  to  support  weak  cases.  Medical  men  have 
fi-equently  been  charged,  and  no  doubt  rightly,  with  too  readily 


382  PSYCHOLOGICAL  MEDICINE 

defending  persons  charged  with  crime  on  a  plea  of  insanity, 
when  the  evidence  has  been  meagre  or  insufficient .  It  is, 
however,  fair  to  remind  the  lawyer,  who  is  disposed  to  reject 
evidence  as  fanciful  and  fantastic,  that  it  is  not  unnatural 
that  a  physician,  whose  life  is  devoted  to  mental  science, 
should  be  able  to  detect  mental  aberration  more  readily  than 
one  without  training  or  experience  upon  the  subject.  Men  of 
known  honour  and  repute  do  not  appear  as  witnesses  to  support 
frivolous  cases  ;  and  in  forming  an  opinion  as  to  whether  a 
particular  person  is  or  is  not  responsible  for  his  actions,  men 
of  equal  integrity  and  skill  may  come  to  different  conclusions, 
even  as  learned  judges  sometimes  differ  both  on  points  of  law 
and  inferences  of  fact.  Modern  tendency  seems  to  indicate 
a  relaxation  on  the  part  of  both  the  lawyer  and  the  physician 
of  their  respective  attitudes  ;  the  subject  is  of  such  supreme 
importance  that  one  may  express  the  hope  that  this  tendency 
may  continue. 

Before  passing  from  this  digression,  the  relationship  of 
law  to  insanity  to  the  relationship  of  lawyer  to  physician, 
a  few  words  might  usefully  be  said  upon  the  too  lax  manner 
in  which  some  medical  men  are  apt  to  give  medical  certifi- 
cates in  order  to  excuse  their  patients  from  duties  which  they 
would  otherwise  have  to  perform  and  which  they  desire  to 
evade.  The  physician  has  not  only  the  welfare  of  his  patients 
in  his  keeping,  but  he  has  also  his  duties  to  his  profession 
and  to  society,  for  these  two  latter  have  entrusted  him  with 
great  responsibilities.  A  medical  certificate  the  pm-port  of 
which  is  to  excuse  a  man  from  performing  some  duty  should 
not  be  made  except  in  hona-jide  cases,  and  the  contents  of 
that  certificate  should  be  absolutely  true  in  fact  and  not 
based  on  some  flimsy  excuse.  Can  it  be  possible  that  this 
ready  granting  of  medical  certificates  in  doubtful  cases  has 
led  the  lawyer  to  distrust  in  some  instances  the  value  of  the 
evidence  of  medical  men  ? 

There  is  another  point  to  Avhich  we  should  like  to  refer, 
and  that  is  the  test  of  msanity  that  is  still  from  time  to  time 
used  in  our  courts  of  justice,  as  to  whether  a  person  knows 
the  difference  between  right  and  wrong.  The  knowledge  of 
right  and  wrong  referred  to  is  knowledge  of  moral  and  legal 
right    and   wrong.     Some   judges    have    now    discarded    this 


THE  RELATIONSHIP  OF  INSANITY  WITH  LAW  383 

obsolete  and  useless  test,  but  instances  from  time  to  time 
occur  in  which  it  is  still  applied.  Never  was  there  devised 
a  more  ill-conceived  test  than  the  test  of  sanity  by  the  pre- 
sence or  absence  of  a  knowledge  of  the  difference  between 
right  and  wrong.  How  could  our  great  asylums  be  adminis- 
tered if  the  majority  of  the  patients  were  ignorant  of  this 
fundamental  law  ?  It  may  unhesitatingly  be  said  that  if 
this  test  were  applied  to  decide  the  legality  of  the  detention 
of  those  at  present  in  the  asylums  of  Great  Britain,  a  very 
large  percentage  of  the  patients  would  have  to  be  discharged 
as  not  '  insane.'  Doubtless  many  of  those  suffering  from 
mental  disorders  are  incapable  of  distinguishing  between 
'  right  and  wrong  '  ;  but,  on  the  other  hand,  there  are  a  great 
number  of  persons  undoubtedly  insane  who  know  when  they 
are  doing  wrong. 

It  must  not  be  forgotten  that  many  of  the  insane  break 
the  moral  code  not  because  they  do  not  recognise  their  action 
as  sinful,  but  because  they  are  biased  by  delusions  or  false 
beliefs.  A  patient  will  tell  you  that  he  knows  he  is  wrong  in 
taking  his  life,  and  yet  he  feels  certain  that  as  long  as  he  lives 
he  is  a  source  of  danger  to  those  about  him. 

The  more  one  analyses  this  test  of  the  knowledge  of  the 
difference  between  right  and  wrong,  the  more  extraordinary 
it  seems  that  such  knowledge  could  ever  have  been  made 
the  crucial  distinction  between  sanity  and  insanity.  It  is 
largely  a  matter  of  education  whether  the  attribute  of  moral 
discrimination  is  acquired  at  all,  and  there  must  be  in  the 
world  a  large  number  of  clearly  sane  persons  whose  know- 
ledge of  the  difference  between  right  and  wrong  is  of  a  very 
rudimentary  nature. 

Probably  we  get  much  nearer  the  truth  when  we  say  that 
the  person  is  insane  who  gratifies  the  desires  of  the  moment 
irrespective  of  all  consequences.  This  definition  is  perhaps 
too  wide,  as  it  would  include  cases  of  crime  under  the  influence 
of  passion  ;  but  if  it  were  necessary  to  pursue  the  matter 
to  a  conclusion,  crimes  of  passion,  whether  of  anger  or  last, 
may  in  many  cases  be  committed  when  the  actor  is  momen- 
tarily insane.  A  person  committing  a  crime  may  fully  realise 
that  he  is  doing  wrong  both  morally  and  in  the  eyes  of  the 
law,  but  owing  either  to  lack  of  power  of  inhibition  or  impelled 


384  PSYCHOLOGICAL  MEDICINE 

b}^  some  delusion  he  acts  without  care  for  the  consequences. 
It  has  been  said  that  a  sane  man  is  reasonablj^  taken  to  '  intend 
all  the  consequences  of  his  own  act,'  but  an  insane  man  may 
surely  act  in  a  similar  manner,  only  he  disregards  the  con- 
sequences when  compared  with  the  pleasure  of  performing 
some  act.  The  reasonable  and  sane  man  no  doubt  carefully 
weighs  his  actions,  and  he  will  not  compromise  his  future 
welfare  and  happiness  by  an  action  which  will  certainlj^  ostracise 
him  from  society. 

Mercier  ^  has  observations  on  this  point  which  may  be  help- 
ful to  the  reader  :  '  Vice  is  the  sacrifice  of  the  future  to  the 
present,  but  of  the  future  of  the  vicious  man  only.'  '  Wrong- 
doing is  the  sacrifice  of  others  to  self.'  '  Wrong-doing  con- 
notes association  with  others  ;  the  existence  of  a  community  ; 
of  a  social  state.'  '  What  we  have  to  ascertain  is  the  dis- 
tinction between  vice  which  is  vice  only  and  vice  which  is 
the  manifestation  of  insanity.'  In  dealing  with  the  question  as 
to  what  constitutes  vice,  Mercier  points  out  that  among  other 
things  the  following  must  be  considered  :  '  (1)  The  gravity 
of  the  difference  between  the  benefit  of  the  immediate  indul- 
gence and  the  benefit  in  the  future  which  immediate  indulgence 
will  forfeit.  (2)  The  proximity  or  remoteness  of  the  advantage 
which  is  forfeited  by  immediate  indulgence.  (3)  The  certainty 
of  the  futm-e  disadvantage.  (4)  The  magnitude  of  the  difference 
between  the  benefit  enjoyed  and  the  benefit  forfeited.' 

He  states  that  '  one  way  (strictly  speaking,  the  only  way) 
in  which  insanity  is  related  to  vice,  is  in  the  weakening,  not 
of  the  perception  of  the  difference  between  the  benefit  and 
the  disadvantage  of  immediate  indulgence,  but  of  the  power 
of  giving  effect  to  the  perception  when  made  ;  of  the  power 
of  postponing  the  immediate  gratification  for  the  sake  of  future 
good.' 

In  deciding  a  question  of  insanity  in  a  person  accused  of 
crime,  it  is  well  for  the  physician  to  investigate  the  mental 
condition  of  the  patient  apart  from  any  consideration  of  the 
crime  ;  in  other  words,  to  examine  the  case  in  the  same  way 
that  he  would  approach  any  ordinary  case.  The  family  history 
should    be  carefully  gone   into   and  a  record  made  of  any 

*  Allbutt's  System  of  Medicine,  '  Vice,  Crime,  and  Insanity,'  vol.  viii. 


THE  RELATIONSHIP  OF  INSANITY  WITH  LAW  385 

instance  of  mental  disorder  or  epilepsy  in  near  relatives.  The 
past  history  of  the  patient  should  be  fully  investigated,  and 
an  inquiry  made  into  any  attack  of  insanity  or  seizure  of 
any  kiad.  The  question  of  epilepsy  should  always  be  borne 
in  mind,  as  both  the  major  and  minor  forms  of  this  disorder 
are  of  great  importance  when  dealing  with  crime.  Petit 
mal  is  of  special  importance,  in  the  first  place  because  it  is  apt 
to  be  overlooked,  and  in  the  second  place  because  persons 
are  especially  liable  to  do  automatic  and  unconscious  acts 
immediately  after  an  attack  of  minor  epilepsy. 

Inqunies  should  be  made  as  to  former  head  injuries,  and 
in  the  event  of  such  a  history  being  given,  evidence  should 
be  taken  as  to  whether  the  injury  had  been  followed  by  any 
alteration  of  conduct  or  mental  capacity.  The  general  habits 
of  life  are  of  importance  and  may  be  helpful  in  deciding  the 
■  question  of  insanity.  Any  eccentricities  should  also  be  noted 
and  the  length  of  time  they  have  been  observed.  We  have 
known  of  a  number  of  cases  where  living  a  solitary  life  abroad, 
in  some  isolated  part  of  Canada  or  Australia,  has  led  to  the 
development  of  suspicions  and  delusions  of  persecution.  Long 
periods  of  ill-health  or  sleeplessness  are  factors  which  must 
not  be  forgotten,  insomnia  being  very  prone  to  induce  mental 
aberration. 

It  is  not  intended  in  this  chapter  to  describe  how  cases 
of  mental  disorder  should  be  investigated,  as  this  will  be 
treated  elsewhere,  but  merely  to  emphasise  points  of  special 
importance.  Further,  it  is  necessary  to  consider  the  crime 
and  how  it  was  done,  remembering  to  inquire  into  what 
appeared  to  be  the  mental  state  of  the  individual  immediately 
before  and  after  the  event.  Note  the  assigned  cause  of  the 
crime.  In  many  cases  the  cause  is  clearly  a  delusion,  or  no 
cause  is  given,  as  the  person  merely  acted  on  impulse.  The 
question  of  motive  is  apt  to  be  misleading,  and  it  is  by  no 
means  uncommon  for  an  insane  person  to  give  a  motive 
which  prima  facie  may  appear  to  indicate  sanity  and  yet 
on  careful  investigation  will  prove  to  be  based  on  some  delusion. 
Homicide  or  acts  of  violence  may  be  done  in  obedience  to 
'  voices  '  or  auditory  hallucinations,  or  may  be  the  result  of 
delusions  of  persecution  in  which  the  patient  believes  that 
he  is  the  victim  of  some  plot  or  conspii'acy.     On  the  other 

25 


386  PSYCHOLOGICAL  MEDICINE 

band,  some  slight  imaginary  insult,  such  as  a  sneer  or  cough, 
the  creation  of  a  distorted  and  hypersensitive  mind,  may 
be  the  determining  factor  in  bringing  about  some  violent 
assault,  which  the  patient  considers  a  legitimate  retaliation 
for  his  "UTongs.  Outrage  may  be  the  product  of  an  insane 
vanity  which  has  been  developing  for  months  or  years.  There 
are  many  cases  in  which  the  violence  seems  to  be  absolutely 
wanton  and  without  motive  ;  and  imbecile  and  weak-minded 
individuals  frequently  act  in  this  way. 

Another  point  to  which  we  would  draw  attention  is  that 
certain  insane  persons,  when  they  have  just  done  some  deed, 
are  apparently  perfectly  sane  and  reasonable.  It  is  also 
commonly  observed  in  cases  of  attempted  suicide,  that  after 
the  attempt  the  patient  seems  to  have  recovered.  In  both 
i-istances  the  explanation  is  probably  due  either  to  shock,  or 
perhaps  more  commonly  to  the  feehng  of  enormous  relief 
experienced  by  a  person  after  the  committal  of  an  act,  the 
impulse  to  which  may  have  been  haunting  him  for  days  and 
weeks.  Such  cases  should  be  placed  under  careful  observation 
for  some  time,  and  even  if  no  mental  aberration  is  noted,  it 
in  no  way  justifies  the  conclusion  that  the  person  was  not 
insane  at  the  time  the  act  of  violence  was  committed.  It  is 
especially  incumbent  on  the  physician  carefully  to  investigate 
these  cases  and  not  to  form  too  rapid  a  conclusion,  otherwise 
a  serious  miscarriage  of  justice  may  result. 

Further,  it  must  be  remembered  that  there  are  a  number 
of  innocent  persons  who  give  themselves  up  to  the  police  for 
some  imaginary  crime.  There  are  alwaj'-s  plenty  of  confused 
and  depressed  individuals  who  are  looking  about  for  some- 
thing whereby  they  can  explain  their  altered  feelings,  and 
when  reading  in  the  newspaper  that  some  crime  has  been 
committed  by  some  unknown  persons,  they  come  to  the 
conclusion  that  they  must  have  done  it,  and  accordingly 
surrender  themselves  to  the  police. 

The  relation  of  alcohol  to  crime  is  often  a  difficult  one  to 
decide,  for  intoxication  per  se  is  no  excuse  for  any  breach  of 
the  law.  But  alcohol  may  be  associated  with  insanity,  and  in 
this  case  the  mental  disorder  must  be  proved.  In  addition  it 
must  not  be  forgotten  that  an  insane  pei'ison  may  endeavomr  to 
nerve  himself  for  some  deed  of  violence  by  taking  stimulants. 


THE  RELATIONSHIP  OF  INSANITY  WITH  LAW  387 

and  that  care  must  be  taken  that  this  is  neither  misconstrued 
into  an  act  of  sanity  nor  the  crime  attributed  to  drink. 

In  conclusion,  the  physician  must  always  be  on  his  guard 
against  feigned  insanity.  The  tests  for  this  latter  have  been 
fully  dealt  with  elsewhere.  Eemember  that  each  case  must  be 
tried  on  its  own  merits,  and  that  after  all  there  is  no  standard 
of  insanity  and  no  ^definition  of  insanity.  Honestly  examine 
every  case,  neither  being  led  away  by  the  entreaties  of  sorrow- 
stricken  relatives,  nor  being  biased  against  the  prisoner  on 
account  of  the  cruelty  of  the  crime.  Ignore  public  opinion  ; 
and  avoid  personal  prejudice.  You  may  hold  strong  views 
against  capital  punishment.  This  must  not  weigh  Avith  you, 
for  the  penalty  is  fixed  by  the  State,  Your  duty  is  to  give 
your  opinion  on  the  question  of  insanity  ;  you  have  nothing  to 
do  with  the  verdict  or  sentence.  Let  your  evidence  be  as  free 
from  technical  words  and  phrases  as  possible.  In  the  chapter 
on  Moral  Imbecility  we  have  referred  to  other  breaches  of  the 
criminal  law  ;  but  so  long  as  the  point  of  issue  is  that  of 
insanity,  the  mode  of  procedure  so  far  as  investigation  is 
concerned  is  similar  to  that  just  recited. 

Before  passing  on  to  the  Civil  Liability  of  the  Insane, 
this  is  a  convenient  place  to  state  the  various  ways  and  times 
the  question  of  insanity  in  prisoners  may  arise.  In  the 
police  court  the  magistrate  has  no  power  to  deal  with  any  ques- 
tion of  insanity.  If  a  pima  facie  case  of  crime  is  shown,  he 
must  commit  the  prisoner  for  trial,  no  matter  how  insane  the 
latter  may  show  himself.  Similarly  a  grand  jury  have  no 
concern  with  any  questions  of  mental  disorder,  and  it  is  not 
until  a  true  bill  has  been  found  against  the  prisoner  and  he 
comes  before  the  court  to  stand  upon  his  trial,  that  any  issue 
of  insanity  may  be  raised.  When  the  accused  is  called  upon 
to  plead,  the  prisoner  may  stand  mute.  The  jury  may  then 
be  asked  to  decide  whether  the  accused  '  is  mute  of  malice,  or 
by  the  visitation  of  God.'  Even  if  a  prisoner  pleads  in  the 
ordinary  way,  the  jury  may  be  asked  whether  the  prisoner 
in  question  is  mentally  fit  to  plead  or  not,  or  it  may  be  worded 
differently  and  the  question  may  be  definitely  asked  '  whether 
he  is  sane  or  not.'  In  all  the  above  instances  which  may  arise 
on  '  arraignment '  (or  being  asked  to  plead),  if  the  jur}^  find  the 
prisoner  insane,  he  is  not  tried,  but  is  ordered  to  be  detained 


388  PSYCHOLOGICAL  MEDICINE 

until  '  his  Majesty's  pleasure  shall  be  known,'  a  form  of 
words  which  means  that  the  prisoner  is  sent  to  a  State  asylum 
for  insane  criminals.  There  is  a  point  here  to  be  noted  which 
is  of  importance,  and  that  is,  if  an  accused  person  is  found 
insane  '  on  arraignment,'  the  question  of  whether  he  were 
insane  at  the  time  when  the  crime  was  committed  is  not 
dealt  with. 

Further,  if  a  prisoner  has  pleaded  in  the  usual  way,  and 
during  the  course  of  the  trial  he  shows  himself  to  be  clearly 
mentally  unfit  to  plead,  the  judge  has  power  to  discharge  the 
jury.  The  question  of  a  prisoner's  sanity  may  be  raised 
during  the  trial  and  evidence  taken  as  to  his  mental  state  at 
the  time  when  the  crime  was  committed.  In  the  event  of  the 
jury  finding  the  prisoner  insane,  he  is  ordered  '  to  be  detained 
during  his  Majesty's  pleasure.'  In  some  cases  the  point  of 
insanity  is  not  raised  during  the  trial,  as  the  legal  advisers 
hope  '  on  the  merits  of  the  case  '  to  get  a  verdict  of  '  not 
guilty,'  in  which  event  the  patient  can  be  placed  under  care 
by  his  friends  if  his  mental  state  is  such  that  it  requires 
treatment.  If  a  prisoner  has  been  found  guilty  and  sentenced, 
the  question  of  mental  disorder  can  still  be  raised  by  applica- 
tion to  the  Home  Secretary,  who,  upon  definite  evidence  being 
given,  will  institute  an  inquiry  into  the  mental  state  of  the 
prisoner.  The  plea  of  insanity  is  most  commonly  made  by  the 
defence,  but  the  Crown  (the  prosecution)  is,  as  a  general  rule, 
very  careful  to  have  the  mental  state  of  all  prisoners  accused  of 
serinns  crimes  investigated  and  reported  upon  by  the  prison 
medical  of&cer  or  a  physician  especially  appointed  for  the  purpose. 

We  must  now  pass  on  to  consider  the  Civil  Liability  of  the 
Insane.  This  has  largely  to  do  with  breach  of  contracts,  or 
the  obligations  of  an  insane  person  for  wrongs  done  to  other 
individuals.  Those  requiring  information  on  the  legal  responsi- 
bilities of  the  insane  will  find  the  matter  fully  dealt  with  in  a 
useful  book  entitled,  '  The  Insane  and  the  Law,'  compiled  by 
Mr.  Pitt-Lewis,  Dr.  Percy  Smith,  and  Mr.  Hawke.  We  quote 
the  following  from  the  section  of  the  '  Liability  of  the  Insane 
upon  Contracts  '  : 

'  If  a  peison  of  sound  mind  make  a  contract,  and  after- 
wards becomes  insane,  his  supervenipg  insanity,  as  a  rule, 
does  not  excuse  him  from  the  performance  of  the  contract 


THE  RELATIONSHIP  OF  INSANITY  WITH  LAW  389 

which  he  has  made  [see  Lecfke  on  Contracts,  page  503].  It, 
however,  reheves  him  from  hability  to  carry  out  a  contract  to 
marry  [as  to  which  see  Cannon  v.  SmaJley  (1885)]  ;  and  it 
perhaps  also  excuses  him  from  the  performance  of  contracts 
to  render  personal  services.  .  .  .  Even  if  an  agent  whose 
authority  is  apparently  continuing,  after  his  principal  has 
become  insane,  enters  into  a  contract  in  good  faith  with  a 
person  who  is  ignorant  of  the  fact  of  the  insanity,  the  insane 
person  will  be  bound  [see  Dreiv  v.  Nunn  (1879)]. 

'  Accordingly,  the  implied  authority  to  pledge  her  hus- 
band's credit  for  "  necessaries  "  which  a  wife  generally 
possesses,  continues  after  the  former  has  become  insane 
[Bead  v.  Legard  (1851)].  An  insane  persor,  moreover,  can 
during  his  insanity,  like  an  infant,  make  a  binding  contract 
for  what  the  law  calls  "  necessaries,"  and  this  whether  the 
insanity  be  known  to  the  other  party  to  the  contract  or  not 
[see  Leake  on  Contracts,  third  edition,  page  505  ;  and  the  lon^ 
series  of  cases  from  Baxter  v.  Earl  of  Bortsmouth,  in  the  year 
1826,  down  to  re  Bhodes  in  1890].'  With  regard  to  the  term 
'  necessaries  '  this  will  largely  be  dependent  upon  social  position 
and  general  circumstances.  '  As  a  general  rule,  however, 
a  person  who  is  in  a  state  of  such  insanity  as  disables  him 
from  making  it,  is  not  bound  by  any  contract  into  which  he 
may  enter,  while  in  that  condition,  with  another  person,  7Dho 
is  aivare  that  he  is  then  insane  [Molton  v.  Camroux  (1848)  ; 
Imperial  Loan  Company  v.  Stone  (1892)].' 

It  is  by  no  means  always  easy  to  prove  that  the  other 
contracting  party  was  aware  that  the  man  with  whom  he 
was  dealing  was  insane.  The  conduct  and  general  behaviour 
of  the  alleged  insane  person  have  largely  to  be  rehed  upon  in 
deciding  whether  any  mental  disorder  must  be  deemed  to 
have  been  apparent  to  the  other  party  to  the  transaction. 
In  the  case  of  contracts,  if  a  man  is  drunk  at  the  time  when 
a  contract  is  entered  into  and  his  state  of  intoxication  is 
known  to  the  other  party,  the  drunkard  is  in  the  same  position 
as  an  insane  person.  A  contract  made  under  such  circum- 
stances is  not  actually  void,  but  is  voidable  at  the  instance  of 
the  insane  or  incompetent  party,  with  whom  rests  the  right 
of  saying  whether  it  shall  stand  good  or  not. 

Continuing  to  quote  from  the  same  authority  :    '  A  valid 


3S0  PSYCHOLOGICAL  MEDICINE 

marriage  cannot  be  contracted  by  a  person  who  is  so  insane 
as  not  to  understand  the  nature  of  the  act.  An  adequate 
degree  of  sanity  is  required  for  contracting  a  valid  marriage, 
just  as  it  is  necessary  to  enable  a  person  to  make  a  valid  will 
or  to  do  other  legal  acts. 

'  The  burden  of  showing  that,  at  the  time  when  the  cere- 
mony of  marriage  was  gone  through,  one  of  the  parties  to 
such  ceremony  was  so  insane  as  not  to  be  capable  of  under- 
standing the  nature  of  the  contract,  and  the  duties  and 
responsibihties  which  it  creates,  rests  upon  any  person  who 
impeaches  the  marriage  on  the  ground  that  insanity  existed 
at  the  time  that  the  ceremony  was  gone  through  [see  Durham 
V.  Durham  (1885)  and  cases  there  cited].  But,  when  the 
existence  of  this  degree  of  insanity  is  proved,  the  Divorce 
Court  will,  on  a  proper  application  being  made  to  it  for  that 
purpose,  declare  the  marriage  null  and  void  [Scott  v.  Sebright 
(1886)].'  From  this  it  will  be  noted  that  '  it  is  not  every 
act  of  an  insane  person  that  is  void,  but  only  the  act  of  every 
person  who  is  so  insane  as  not  to  be  capable  of  understanding 
and  appreciating  that  particular  act. 

'  When  a  valid  marriage  has  once  been  contracted,  if  one 
of  the  parties  to  it  afterwards  becomes  insane,  this  affords  the 
other  party  no  gromid  for  obtaining  a  divorce.' 

Dealing  now  with  wTongs  to  others,  apart  from  contracts, 
we  find  that  '  an  insane  person  is,  in  general,  responsible 
for  any  wrong  or  injury  to  the  person,  character,  or  property 
of  another  which  may  be  committed  by  him.'  Messrs.  Pitt- 
Lewis  and  Percy  Smith,  in  '  The  Insane  and  the  Law,'  state 
the  case  as  follows  :  '  The  law,  in  other  words,  looks  to  the 
damage  done  to  the  injured  person,  and  not  to  the  mind  of 
the  injurer  ;  for  it  is  impossible  to  "  try  the  thought  of  man," 
or  to  find  out  what  intention  was  existing  in  the  mind  of  an 
aggressor  at  any  given  moment  ;  and  therefore  the  law  holds 
that  every  man  is,  by  law,  taken  to  intend  the  natural  and 
reasonable  consequences  which  follow  from  any  act  of  his, 
altogether  irrespectively  of  the  actual  state  of  liis  mind  at 
the  moment  he  commits  it.' 

Bacon  {Abridgement,  Trespass  G)  laid  down  the  law  as 
follows  :  '  An  action  for  trespass  may  be  brought  against 
a   lunatic,   notwithstanding   he  is   incapable   of   design  ;    for 


THE  RELATIONSHIP  OF  INSANITY  WITH  LAW  391 

wherever  one  person  receives  an  injury  from  the  voluntary  act  of 
another,  this  is  trespass,  though  there  was  no  desire  to  injure.' 
Apparently  the  law  also  holds  an  insane  person  responsible 
for  any  libel  on  another  party.  Nevertheless,  it  must  be 
borne  in  mind  that  though  a  person  of  unsound  mind  may 
be  held  legally  responsible  for  his  actions  in  the  matter  of 
wrongs  to  others,  the  question  of  damages  must  not  ■  be 
forgotten.  If  a  person  is  clearly  insane,  the  probability  is 
that  the  damages  would  be  purely  nominal. 

Testamentary  Ca-pacity 

The  elements  that  are  necessary  to  the  competency  of  a 
testator  at  the  time  of  making  his  will  are — 

(a)  An  understanding  of  the  nature  of  the  business  on 
which  he  is  engaged. 

(6)  A  recollection  of  the  property  of  which  he  means  to 
dispose. 

(c)  A  remembrance  of  the  persons  who  have  a  claim  to  be 
the  objects  of  his  bounty,  and  a  recognition  of  the  relative 
strength  of  these  claims. 

{d)  An  appreciation  of  the  manner  in  which  he  desires 
his  property  to  devolve. 

To  deal  first  with  heads  (a)  and  {d),  it  will  at  least  be  con- 
ceded that  a  testator  should  understand  that  the  document 
which  he  is  executing  purports  to  direct  the  disposition  of 
his  property  on  his  death  ;  and,  further,  that  he  should  have 
a  clear  comprehension  of  the  manner  in  which,  and  of  the 
persons  among  whom,  he  desires  that  property  to  be  divided. 

As  regards  head  (&),  the  expression  used  in  the  above  state- 
ment is  perhaps  somewhat  insufficient.  The  law  does  not 
require  a  detailed  knowledge  in  the  testator  of  items  of  his 
property  which  would,  in  the  absence  of  definite  disposition, 
naturally  fall  into  the  residue  of  his  estate.  It  requires  only 
a  fair  estimate  of  the  extent  of  his  property,  that  the  testator 
may  not,  on  the  one  hand,  by  an  unreasonable  fear  of  his 
financial  state,  confine  his  bounty  within  unnatural  limits,  or, 
on  the  other  hand,  by  an  exalted  appraisement  of  his  riches,  so 
lavishly  divide  it  as  to  benefit  neither  friend  nor  charity. 

Passing  to  head   (c),  the  words  of  Erskine  in  the  case  of 


392  PSYCHOLOGICAL  MEDICINE 

Harwood  v.  Baher  (1840),  3  Moore,  P.O.  282,  emphasise  the 
importance  of  this  safeguard  : 

'  The  protection  of  the  law  is  in  no  case  more  needed  than 
in  those  where  the  mind  has  been  too  much  enfeebled  to 
comprehend  more  objects  than  one,  and  most  especially  when 
that  one  object  may  be  so  forced  upon  the  attention  of  the  invalid 
as  to  shut  out  all  others  that  might  require  consideration.' 

This  brief  account  of  the  tests  applied  by  the  law  to  the 
physical  and  mental  condition  of  a  would-be  testator  will 
show  that  the  question  of  testamentary  capacity  or  incapacity 
is  one  of  fact.  That  sanity  or  insanity  is  a  question  of  fact 
is  equally  true,  but  the  words  testamentary  capacity  or  incapa- 
city are  advisedly  used  ;  for,  as  will  presently  appear,  sanity 
and  testamentary  capacity  are  not  necessarily  equivalent 
terms.  Where  there  is  congenital  idiocy,  it  is  obvious  that 
there  can  be  no  effective  testamentary  power.  Take,  however, 
the  case  of  a  patient  suffering  from  delusional  insanity  who 
desires  to  make  a  will.     Can  he  validly  do  so  ? 

In  such  cases  the  view  formerly  taken  in  our  courts  of  justice 
was  that  the  mind  is  '  one  and  indivisible,'  and  that  unsound- 
ness in  one  particular  involved  unsoundness  in  the  whole. 
The  modern  view  has  tended  to  a  different  test.  The  answer 
now  depends  on  whether  the  delusions  are  of  such  a  character 
as  to  warp  the  judgment  of  the  testator  in  any  of  the  respects 
comprised  in  the  heads  referred  to  above  as  (a)  to  {d). 

This  view  is  supported  by  Legrand  in  '  La  Folie  devant  les 
Tribunaux,'  where  he  contends  that  '  hallucinations  are  not 
sufficient  obstacle  to  the  power  of  making  a  will,  if  they  have 
exercised  no  influence  on  the  conduct  of  the  testator,  have 
not  altered  his  natural  affections,  or  perverted  the  fulfilment  of 
his  social  and  domestic  duties  ;  while,  on  the  other  hand,  the 
will  of  a  person  affected  by  insane  delusiojis  ought  not  to  be 
admitted  if  he  has  disinherited  his  family  without  cause,  or 
looked  on  his  relations  as  enemies,  or  accused  them  of  seeking 
to  poison  him,  or  the  like.  In  all  such  cases,  where  the  delusion 
exercises  a  fatal  influence  on  the  acts  of  the  person  affected, 
the  condition  of  the  testamentary  power  fails  ;  the  will  of  the 
party  is  no  longer  under  the  guidance  of  reason,  it  becomes 
the  creature  of  the  insane  delusion.' 

We  will  give  illustrations  of  cases  on  each  side  of  the  line. 


THE  RELATIONSHIP  OF  INSANITY  WITH  LAW  393 

To  those  considering  their  effect,  a  warning  may  be  necessary 
against  accepting  too  impHcitly  the  statements  made  on  either 
side.  Evidence  given  Avhich  would  seem  clearly  to  estabhsh 
insanity  is  not  necessarily  true  and  may  not  be  accepted  by 
the  Court  in  coming  to  its  decision.  The  tendency  of  the 
party  propounding  a  will  is,  without  conscious  dishonesty,  to 
view  the  testator's  condition  in  the  light  most  satisfactory  to 
his  contention. 

Thus  the  beneficiary  under  the  will  may  be  expected  to 
regard  his  selection  as  beneficiary  as  an  irrefutable  sign  of  the 
testator's  sanity,  while  the  exclusion  of  the  party  disputing 
the  will  seems  to  himself  an  equally  cogent  proof  of  insanity. 
So  one  may  expect  to  find  both  a  behttling  and  an  exaggera- 
tion of  eccentricity. 

In  Banks  v.  GoodfeUow  (1870),  L.  R.  5  Q.B.  549,  it  appeared 
that  the  testator  made  the  will  in  dispute  in  1863  :  he  had 
been  confined  as  a  person  of  unsound  mind  for  some  months 
in  1841,  and  he  remained  to  his  death  subject  to  delusions 
that  he  was  molested  by  a  man  who  had  long  been  dead, 
and  that  he  was  pursued  by  evil  spirits  which  he  believed 
to  be  visibly  present.  As  to  the  testator's  general  capacity 
to  manage  his  affairs  the  evidence  was  contradictory  ;  but 
the  Court  seemed  to  favour  the  opinion  that  his  mental  power 
was  sufficient  for  this  work.  The  jury  found  that  the  testator 
was  capable  of  having  such  a  knowledge  and  appreciation 
of  facts,  and  was  so  far  master  of  his  intentions,  and  free  from 
delusions,  as  would  enable  him  to  have  a  will  of  his  own  in 
the  disposition  of  his  property,  and  act  upon  it. 

Cockburn  (Chief  Justice)  set  forth  in  very  clear  language 
the  measure  of  the  degree  of  mental  power  which  should  be 
insisted  upon  :  '  If  the  human  instincts  and  affections  or  the 
moral  sense  become  perverted  by  mental  disease  ;  if  insane 
suspicion  or  aversion  take  the  place  of  natural  affections  ;  if 
reason  and  judgment  are  lost,  and  the  mind  becomes  a  prey 
to  insane  delusions,  calculated  to  interfere  with  and  disturb 
its  functions,  and  to  lead  to  a  testamentary  disposition,  due 
only  to  their  baneful  influence  ;  in  such  a  case  it  is  obvious 
that  the  condition  of  testamentary  power  fails,  and  that  a 
will  made  under  such  circumstances  ought  not  to  stand.  But 
what  if  the  mind,  though  possessing  sufficient  power,  undis- 


394  PSYCHOLOGICAL  MEDICINE 

turbed  by-  frenzy  or  delusion,  to  take  into  account  all  the 
considerations  necessary  to  the  proper  making  of  a  will,  should 
be  subject  to  some  delusion,  but  such  delusion  neither  exercises, 
nor  is  calculated  to  exercise,  any  influence  on  this  particular 
disposition,  and  a  rational  and  proper  will  is  the  result  ;  ought 
we,  in  such  a  case,  to  deny  to  the  testator  the  capacity  of  dis- 
posing of  his  property  by  will  ?  ' 

It  is  to  be  observed  that  the  delusions  of  the  testator  in  this 
case  were  not  of  a  sort  to  affect  his  bequest.  The  man  to 
whom  the  testator  attributed  molestation  had  been  long  dead, 
and  he  was  not  a  relative,  and  his  children  would  not  in  any 
event  have  been  natural  objects  of  the  testator's  bounty. 
The  hallucinations  of  sight  and  the  persecution  by  evil 
spirits  had  no  direct  relation  to  the  matter  in  dispute.  No 
evidence  was  offered  that  any  of  the  delusions  aHenated 
from  the  affections  of  the  deceased  any  of  his  relations 
or  friends,  or  injured  his  mind  in  such  a  way  as  to  prevent  his 
due  consideration  of  the  matters  set  out  above. 

In  Smee  v.  Sm.ee  (1879),  5  P.  D.  84,  the  deceased  met  with 
a  severe  railway  accident  in  1852,  in  consequence  of  which  he 
resigned  his  appointment  in  the  Bank  of  England  in  1854. 
In  the  same  year  he  was  married.  By  a  will  in  1859  he  left 
his  property  to  his  wife  absolutely,  subject  only  to  some  small 
legacies.  By  a  will  in  1867  he  left  her  his  property  for  Hfe 
or  widowhood,  with  remainder  to  the  Brighton  Corporation. 
The  deceased  managed  his  affairs  to  his  death,  took  an  active 
part  in  politics,  and  among  other  things  wrote  an  able  article 
on  the  repeal  of  the  malt  tax.  His  delusions  were  embodied 
in  a  memorial  addressed  to  the  Queen.  Shortly,  he  thought 
that  his  supposed  father  was  not  his  father  ;  that  he  was 
connected  with  the  Eoyal  Family  ;  that  his  father  drugged 
him  ;  that  he  had  a  secret  interview  with  the  Duke  of  Welling- 
ton disguised  as  a  mechanic  ;  that  the  drugging  temporarily 
obliterated  his  memory,  which  suddenly  returned  owing  to 
the  effusion  of  l)l()od  occasioned  by  the  accident  ;  that  his 
brother  had,  by  the  fraud  of  his  father,  been  put  in  possession 
of  property  which  should  have  been  his.  The  jury  found  that 
the  deceased  was  not  of  sound  mind  when  the  wills  were 
executed,  and  they  were  accordingly  pronounced  against. 
Here  it  will  be  noticed  that  the   delusions  from  which  the 


THE  RELATIONSHIP  OF  INSANITY  WITH  LAW  395 

deceased  suffered  changed  his  feehngs  towards  his  father  and 
brother,  and  made  it  impossible  to  say  that  the  elements  which 
went  to  make  up  testamentary  capacity  were  all  present. 

In  the  case  of  Boe  v.  Nix,  decided  in  1892,  we  find  a  some- 
what extreme  illustration  of  the  application  of  this  branch  of 
law.  Miss  Eoe  died,  aged  sixty-seven,  leaving  a  document  which 
was  propounded  as  a  valid  will  by  one  of  the  legatees.  Under 
its  provisions  it  appeared  that  she  had  slowly  been  becoming 
peculiar  in  her  habits  and  was  in  1884  placed  under  inquisition. 
She  was  in  various  asylums,  and  ultimately  went  to  the  Hollo - 
way  Sanatorium  in  1890.  She  continued  to  be  visited  by  the 
Lord  Chancellor's  Visitors  in  Lunacy.  Evidence  was  given 
that  on  September  3,  1888,  one  of  the  Visitors  wrote,  in  reply 
to  her,  that  she  was  quite  capable  of  making  a  will.  This 
expression  must  be  admitted  to  be  equivocal,  as  the  making 
of  a  will  and  its  validity  when  made  cannot  be  said  exactly 
to  correspond.  In  1888  and  1889  she  made  wills,  for  the 
preparation  of  which  a  solicitor  was  instructed.  In  September 
1891,  while  at  the  Convalescent  Home  of  the  Holloway  Sana- 
torium, she  executed  this  will  propounded.  It  was  discussed 
between  her  brother  and  herself  and  was  in  the  handwriting 
of  the  testatrix.  Under  it  the  brother  alone  of  her  family 
received  benefit.  Some  nurses  and  officials  and  the  Medical 
Superintendent  of  the  Sanatorium,  and  the  lawyer  who  pre- 
pared the  earlier  wills,  spoke  favourably  of  the  testamentary 
capacity  of  the  deceased. 

The  jury  found  for  all  the  wills,  a  finding  which  in  law 
amounts  to  the  establishment  of  the  last.  Thus  we  advance 
from  the  proposition,  '  Was  the  testator  sane  or  insane  ?  '  to  a 
narrower  proposition,  '  Was  the  testator  sane  or  insane  for 
the  'purijose  of  making  a  will  ?  '  Similar  reasoning  governs 
the  decision  of  cases  where  the  testator  has  been  admittedly 
insane  both  before  and  after  the  execution  of  the  testamentary 
act,  and  even  where  the  patient  was  at  the  time  of  its 
execution  under  certificates,  or  a  person  of  unsound  mind  so 
found  by  inquisition  not  superseded.  And  here  the  word 
'  insane  '  is  used  as  importing  what  is  known  to  lawyers  as 
'  general  insanity,'  affecting  the  whole  of  the  functions  of  the 
mind  during  its  continuance,  as  distinguished  from  the  '  partial 
insanity  '  of  certain  delusional  states. 


396  ■  PSYCHOLOGICAL  MEDICINE 

Lawyers  have  a  term  '  lucid  interval,'  which  is  stated-  to 
be  the  condition  in  the  above-mentioned  cases.  By  a  '  lucid 
interval '  they  imply  that  a  patient  is  in  such  a  mental  state  as 
to  be  capable  of  transacting  business  or  performing  such  acts 
as  the  making  of  wills.  In  every  case  in  which  testamentary 
capacity  is  challenged,  the  question  to  be  determined  is  one 
of  fact  and  turns  upon  its  own  peculiar  circumstances.  No 
theory  of  law  can  be  more  elastic  than  this.  That  every  case 
should  be  tried  and  decided  on  its  owt.i  merits,  unfettered  by 
legal  presumption  or  doctrines,  is  surely  the  best  and  fairest 
of  rules. 

In  truth,  the  whole  law  on  this  subject,  when  analysed, 
amounts  to  this  :  that  testamentary  capacity  is  a  question  of 
fact,  not  of  law.  At  this  point,  however,  the  defect  creeps  in. 
It  is  a  defect  in  the  constitution  of  the  tribunal  which  sits  to 
decide  cases  of  this  character.  The  duty  of  the  presiding 
judge  ends  with  an  explanation  of  the  rules  set  out  above 
and  a  summary  of  the  facts  which  seem  worthy  of  the  con- 
sideration of  the  jury.  The  jury  have  then  to  decide  whether 
the  deceased  was  or  was  not  possessed  of  testamentary  capacity. 
The  province  of  the  jury  is  most  difi&cult.  They  have  to 
weigh  evidence,  on  the  one  side  and  the  other,  contradictory 
to  the  last  degree  ;  they  have  to  consider  eccentricities  and 
disorders  of  which  they  have  no  experience  ;  and  to  pronounce 
upon  fine  questions  of  psychology  which  iivdj  have  no  answer. 
Whether  insanity  necessarily  affects  the  wdiole  mind,  whether 
the  mind  is  '  one  and  indivisible,'  is  a  problem  w^hich  has  divided 
schools  of  mental  science,  and  yet  this  problem  is  offered  for 
solution  to  twelve  gentlemen,  maybe  free  from  all  suspicion 
of  scientific  knowledge,  distracted  by  conflicting  evidence, 
unfamiliar  alike  with  their  surroundings  and  their  subject. 
It  may  well  l)e  a  matter  for  surprise  that  they  i^erform  the 
duties  imposed  upon  them  so  creditably. 

But  it  may  also  l)e  doubted  whether  a  more  effectual  tribunal 
might  not  be  devised.  To  make  a  suggestion,  would  not  a 
judge,  assisted  by  two  experts  in  mental  disease,  as  assessors, 
form  a  board  more  competent  to  deal  Avith  questions  of  so 
difficult  a  nature  ?  The  assessors  would  supply  the  knowledge 
of  the  special  subject,  so  requisite  in  any  tribimal  ;  and  the 
lawyer  would  keep  the  inquiry  within  bounds  and  direct  its 


THE  RELATIONSHIP  OF  INSANITY  WITH  LAW  397 

course.  It  seems  strange  that  our  courts  should  be  granted 
the  assistance  of  the  Elder  Brethren  of  Trinity  House  when 
a  story  of  the  sea  is  to  be  told  ;  while  the  infinitely  more  obscure 
secrets  of  psychology  should  be  offered  to  them  for  their  unaided 
solution.  This,  however,  is  a  defect  due  to  the  Legislature, 
and  not  to  the  administrative  body  of  the  law  ;  such  a  change 
cannot  be  wrought  by  Bench  or  Bar  ;  it  must  originate  with 
Parliament. 

To  sum  up,  we  cannot  do  better  than  to  quote  the  follow- 
ing statements  from  Tuke's  '  Dictionary  of  Psychological 
Medicine  '  : 

'  1.  A  testator  must  be  able  at  the  time  when  he  makes 
his  will  both  to  recall  and  to  keep  clearly  before  his  mind 
(a)  the  nature  and  extent  of  his  property,^  and  (b)  the  persons 
who  have  claims  upon  his  bounty  ;  and  his  judgaient  and 
will  must  be  sufficiently  unclouded  and  free  to  enable  him  to 
determine  the  relative  strength  of  these  claims. 

'  II.  An  insane  person  can  make  a  valid  will  if  (a)  in  spite 
of  his  insanity  he  has  a  disposing  memory,  judgment,  and 
will  as  defined  above,  or  (6)  he  is  enjoying  what  is  called  a 
"  lucid  interval  "  at  the  date  of  its  execution. 

'  III.  A  "  lucid  interval  "  is  not  necessarily  a  complete 
restoration  to  mental  vigour  previously  enjoyed  ;  nor  is  it 
merely  the  cessation  or  suppression  of  the  symptoms  of  insanity 
{Dyce  Sombre  v.  Prinseps,  1856,  per  Sir  John  Dodson,  1  Deane, 
at  p.  110):  it  is  the  recovery  of  testamentary  memory, 
judgment,  and  will. 

'  IV.  Neither  subsequent  suicide  nor  supervening  insanity 
will  be  reflected  back  upon  previous  eccentricities,  so  as  to 
invalidate  a  will  (cf.  Hobij  v.  Hobij,  1828,  per  Sir  John  Nichol, 
1  Hagg.  146  ;  aliter  in  the  case  of  previous  insanity,  Sijmes  v. 
Green,  1859,  1  S.  and  T.  401). 

'  V.  Upon  the  executor  who  propounds  a  will  rests  the 
burden  of  proving  (a)  testamentary  capacity  ;  (b)  knowledge 
and  approval  of  its  contents,  and  (c)  due  execution.  ...  A 
testatrix  gave  instructions  for  her  will,  which  was  prepared  in 
accordance  therewith.  At  the  time  of  execution  the  testatrix 
merely  recollected  that  she  had  given  those  instructions,  but 
believed  that  the  will  which  she  was  executing  accurately 

^  With  regard  to  '  extent,'  this  is  dealt  with  fully  on  p.  381 . 


398  PSYCHOLOGICAL  MEDICINE 

embodied  them.  Sir  James  Hannen  held  that  this  will  was 
valid  {Parkes  v.  Felgate,  1883,  8  P.  and  D.  171,  173,  174).  If 
the  testatrix  had  merely  authorised  her  solicitors  to  make  a 
will,  and  had  she  said,  "I  do  not  know  what  you  have  put 
down,  but  I  am  quite  prepared  to  execute  it,"  the  will  would  be 
invalid.  {Hastilow  v.  Stohie,  1865,  P.  and  D.  64  ;  overruling 
dicta  of  Sir  Creswell  Creswell  in  (a)  Middlehurst  v.  Johnson, 
1860,  30  L.  J.  Prob.  14,  and  (b)  Cunliffe  v.  Crosse,  1863,  3  S. 
and  T.  36.) 

'  VI.  Prima  facie,  an  executor  is  justified  in  propounding 
his  testator's  will,  and  if  the  facts  within  his  knowledge  at 
the  time  he  does  so  tend  to  show  eccentricity  merely  on  the 
part  of  the  testator,  and  he  is  totally  ignorant  at  the  time  of 
the  circumstances  and  conduct  which  afterwards  induce  a 
jury  to  find  the  testator  was  insane  at  the  time  of  the  will,  he 
will,  on  the  yrincijile  that  the  testator's  conduct  was  the  cause  of 
litigation,  be  entitled  to  receive  his  costs  out  of  the  estate, 
although  the  will  be  pronounced  against  him  (cf.  Broughton  v. 
Knight  Knight,  1873,  per  Sir  James  Hannen,  3  P.  and  D.  pp. 
77-80,  and  Smee  v.  Smee,  1875,  5  P.  and  D.  at  p.  90).' 

With  regard  to  this  latter  paragraph,  each  case  must  rest 
on  its  own  merits,  as  clearly  that  which  one  person  might  con- 
sider as  definite  indication  of  insanity,  and  insanity  of  such 
a  nature  as  to  interfere  with  sound  testamentary  capacity, 
another  person  might  overlook  or  treat  as  eccentricity.  From 
what  we  have  stated,  the  physician  will  understand  how  im- 
portant it  is  to  take  full  notes  at  the  time  when  called  in  to 
examine  the  mental  state  of  a  person  who  is  about  to  execute 
a  will.  Trust  nothing  to  the  memory,  as  it  may  be  months 
or  years  before  your  evidence  is  required.  Always  observe 
a  person  carefully  to  see  that  he  is  in  no  way  under  the 
influence  of  alcohol  or  any  other  drug.  See  the  patient  alone, 
except  with  the  nurse,  and  carefully  note  whether  he  appears 
to  be  controlled  or  influenced  by  any  person  or  persons. 
Inquire  as  to  his  bearing  and  friendliness  towards  his  relatives. 
If  possible,  learn  whether  the  individual  in  question  has  ever 
previously  executed  a  will,  and  if  so,  in  what  ways  it  differs 
from  the  proposed  will.  Inquire  how  long  he  has  thought  of 
disposing  of  his  property  in  the.  manner  suggested,  and  if 
there  is  any  sudden  cancelling  of  former  recipients  from  the 


THE  RELATIONSHIP  OF  INSANITY  WITH  LAW  399 

benefits   of    the    will,    learn,    if    possible,   the    cause    of    the 
change. 

It  must  always  be  remembered  that  whatever  is  given  in 
confidence  to  a  medical  man  is  a  professional  secret,  but  some 
information  is  of  vast  importance  and  may  prove  invaluable 
if  the  wall  is  contested.  Information  given  before  an  actual 
suit  is  commenced,  and  especially  if  given  years  before  a 
disagreement,  always  carries  more  weight  with  it  than  infor- 
mation given  after  an  action  has  been  started,  for  then  it  may 
savour  of  being  an  afterthought. 

Carefully  test  the  memory  both  for  recent  and  remote 
events,  and  let  your  examination  be  thorough,  as  the  question 
of  memory  may  be  an  important  one.  Observe  whether  any 
delusion  is  expressed,  and  if  so,  the  nature  of  the  false  belief, 
whether  it  is  likely  to  have  any  definite  bearing  on  the  act 
about  to  be  performed.  Eemember  that  an  individual  may 
have  an  excellent  memory  for  remote  events,  for  this  memory 
is  more  organised,  and  yet  recent  memory  may  be  very  de- 
fective. This  is  especially  the  case  in  seniHty  and  certain 
forms  of  mental  disorder.  Failure  of  recent  memory  may 
seriously  interfere  with  the  testamentary  capacity.  Aphasia 
frequently  renders  a  person  incapable  of  making  a  will,  for 
many  of  these  patients  are,  in  addition,  unable  to  write,  and 
therefore,  for  obvious  reasons,  it  is  difficult  to  make  out  what 
their  wishes  are  for  the  purposes  of  drawing  up  a  will. 

If  possible,  see  the  patient  more  than  once,  and  observe 
whether  he  expresses  the  same  intentions  for  disposing  of  his 
property  on  both  occasions.  In  case  of  doubt  as  to  the  mental 
state  of  the  testator,  call  in  a  colleague,  as  too  much  care  cannot 
be  taken  in  view  of  the  will  being  contested  at  some  subsequent 
time.  Bear  in  mind  w^hat  has  been  already  stated,  that  the 
question  of  testamentary  capacity  is  largely  one  of  facts, 
and  the  more  facts  a  physician  is  able  to.  collect  the  easier 
will  it  be  for  the  jury  to  decide  whether  the  testator  was 
possessed  of  a  '  disposing  memory,  judgment,  and  will.' 


400  PSYCHOLOGICAL  MEDICINE 


GHAPTEE  XXIII 

SLEEPLESSNESS 

The  subject  of  sleep  and  its  disorders  is  of  such  importance 
as  to  merit  a  separate  chapter  for  its  consideration.  The 
faculty  of  being  able  to  sleep  soundly  is  one  of  the  greatest 
privileges  of  which  a  man  can  be  possessed.  While  asleep, 
the  weary  man  is  oblivious  of  his  cares  and  the  over-anxious 
man  forgets  his  worries.  After  healthy  sleep  mind  and  body 
are  alike  refreshed  ;  the  sense  of  fatigue  has  disappeared,  and 
the  capacity  for  work  is  renewed.  Without  sleep  hfe  becomes 
a  burden  ;  the  nights  are  spent  wearily  tossing  about,  and  the 
day  dawns  to  find  mental  and  physical  vigour  rather  lessened 
than  renewed. 

The  living  organism  which  cannot  sleep  must  die  ;  and 
slowly  but  surely  the  dissolution  advances.  The  man  who 
never  sleeps  steadily  degenerates  ;  his  muscles  will  no  longer 
perform  dehcate  movements  and  his  mental  powers  diminish. 
Attention  fails  and  the  power  of  thought  disappears.  At  first 
it  is  all  the  higher  attributes  that  are  affected,  but  as  time 
passes  the  disorder  spreads  to  the  lower  functions.  The  appe- 
tite is  lost  and  food  is  no  longer  assimilated.  The  functions 
of  the  various  organs  are  no  longer  properly  carried  out  and 
the  physical  health  suffers.  Insomnia  first  maims,  then  kills. 
At  first  the  finest  and  most  highly  dififerentiated  systems 
become  disorganised,  for  these  are  the  weakest  Hnks  in  the 
chain  ;  thus  reason  is  early  in  jeopardy.  It  may  take  years 
of  sleeplessness,  unless  the  insomnia  is  very  profound,  before 
life  itself  is  threatened  ;  but  as  the  wearing-down  process 
continues,  the  day  must  come  when  every  organ  of  the  body 
suffers  from  the  want  of  rest  and  becomes  disorganised. 

The  importance  of  obtaining  proper  sleep  is  not  fully  realised 
by  the  average  man.     He  fails  to  grasp  the  part  that  sleep 


SLEEPLESSNESS  401 

plays  in  the  economy  of  the  organism  and  too  readily  neglects 
to  study  its  requirements.  Sleep  is  a  habit,  and  a  habit  which 
should  be  jealously  maintained.  As  in  the  case  of  meals,  it 
should  be  taken  at  a  regular  time  ;  otherwise  the  appetite  may 
be  lost  with  the  waiting.  Life  is  to-day  so  artificial  that 
nights  are  often  turned  into  days,  without  a  thought  that  the 
habit  formed  in  childhood  of  retiring  to  rest  at  a  regular  time 
is  being  disturbed.  Once  the  habit  of  going  to  sleep  at  a 
certain  hour  is  broken,  there  may  be  months  of  insomnia 
before  it  becomes  re-established. 

It  is  impossible  and  inappropriate  to  discuss  here  the 
various  theories  of  sleep.  The  student  must  read  this  subject 
in  some  work  of  physiology.  For  convenience,  however, 
some  of  the  views  held  at  the  present  time  may  be  briefly 
enumerated  : 

(a)  That  sleep  is  due  to  a  diminution  in  the  blood-supply 
to  the  brain,  to  an  anaemic  condition  of  the  brain. 

(b)  That  it  is  due  to  an  expansion  of  the  neuroglia  cell 
processes. 

(c)  That  it  -'s  due  to  ci't  action  of  the  dend  ons  resilti  g 
iu  a.n  i  termptio  i.  in  tLe  t:a  smis^iion  of  nervous  impulsas. 

(d)  That  it  is  due  to  chemical  changes  in  the  brain  cells 
arising  from  an  accumulation  of  fatigue  products. 

The  disorders  of  sleep  are  of  several  kinds.  Sleep  may 
be  defective  in  quantity  or  quality,  or  in  both  these  respects. 
The  actual  amount  of  sleep  necessary  for  persons  in  health 
varies  greatly  according  to  age,  temperament,  and  soundness 
of  sleep  enjoyed.  The  young  require  much  more  sleep  and 
rest  than  the  aged  ;  the  active  disposition  should  have  longer 
hours  of  repose  than  the  apathetic  and  indolent.  Children 
and  young  adults  should  have  always  nine  or  ten  hours  in 
bed,  and  even  in  middle  life  the  number  of  hours  allotted  for 
sleep  should  not  be  under  eight.  The  '  light '  usually  requires 
more  rest  than  the  '  heavy  '  sleeper,  and  persons  whose  sleep 
is  constantly  being  broken  by  dreams  should  allow  themselves 
longer  time  in  bed.  The  aged  usually  get  only  five  or  six 
hours'  sleep  at  night  ;  but  as  they  have  a  faculty  of  taking 
frequent  naps  during  the  day,  they  probably  average  about 
the  same  as  the  adult  of  middle  life.  The  amount  of  sleep 
may  be  excessive.     A  person  may  spend  ten  or  twelve  hours, 

26 


402  PSYCHOLOGICAL  MEDICINE 

and  even  more,  in  bed,  and  when  up  may  be  constantly  drop* 
ping  off  to  sleep.  The  degenerate  are  frequently  very  drowsy, 
and  certain  types  of  idiots  and  imbeciles  spend  a  great  portion 
of  their  time  asleep.  Again,  towards  the  end  of  life  with 
senility,  a  great  tendency  to  fall  asleep  at  all  times  of  the 
day  may  be  observed.  Persons  suffering  from  organic  brain 
disease  usually  become  very  somnolent,  and  the  same  symptom 
is  very  noticeable  in  other  disorders. 

The  amount  of  sleep  may  be  defective  in  quantity.  In- 
somnia is  one  of  the  most  urgent  symptoms  that  we  are  called 
upon  to  treat  in  cases  of  mental  disorder.  The  sleeplessness 
may  be  very  marked,  and  the  patient  may  lie  awake  night 
after  night.  Some  persons  drop  off  to  sleep  soon  after  retiring 
to  bed,  but  wake  again  an  hour  or  two  after  and  spend  the 
rest  of  the  night  in  wakefulness  ;  others  are  restless  on  re- 
tiring to  bed  and  fail  to  get  sleep  until  five  or  six  o'clock  in 
the  morning. 

The  effects  of  insomnia  vary  in  different  individuals  ;  one 
man  will  lie  quietly  in  bed,  in  spite  of  not  being  able  to  sleep, 
while  another  will  become  fidgety  and  restless,  turning  from 
side  to  side,  and  finally  in  desperation  will  get  up  and  wander 
about  the  room  or  house.  Clearly  the  effect  is  much  more 
serious  on  the  latter  than  upon  the  man  who  is  placid  and 
takes  all  the  rest  he  can  get.  A  person  nia,j  sleep,  but  the  sleep 
may  be  very  disturbed  and  of  a  restless  character.  Dreams 
may  be  vivid  and  terrifying  and  cause  the  nights  to  be  hours 
of  torture  rather  than  repose.  ' 

Sleep  may  l)e  abnormal  in  other  ways.  Somnambulism  is 
common  in  children  and  3'oung  adults  whose  parentage  is  of 
a  neurotic  t vpe.  The  person  may  or  may  not  have  a  recollection 
of  his  somnambulistic  acts  when  he  awakes,  the  memory  being 
dependent  upon  the  depth  of  sleep  at  the  time  of  the  sleep- 
walking. Talking  during  sleep  is  another  abnormal  symptom 
not  infrequently  encountered.  Night  terrors  are  not  un- 
common in  children  and  adults  with  a  neuropathic  heredity  ; 
they  may  see  all  kinds  of  imaginary  oljjects. 

The  causes  of  sleeplessness  are  numerous.  German  See 
has  drawn  up  the  following  useful  classification  of  types  of 
insomnia  :  (a)  Dolorous  Insomnia  ;  (b)  Digestive  ;  (c)  Cardiac 
and  dyspnoeal ;   {d)  Cerebro-spinal,  neurotic  (General  Paralysis 


SLEEPLESSNESS  403 

of  the  Insane,  Mania,  etc.)  ;  (e)  Psychic  Insomnia  (emotional 
and  sensorial)  ;  (/)  Insomnia  due  to  physical  and  cerebral 
fatigue  ;  {g)  Genito-iu'inary  Insomnia  ;  (h)  Febrile,  infectious, 
autotoxic  ;  (i)  Toxic  Insomnia  (tea,  coffee,  etc.).  Sleeplessness 
due  to  the  above  causes  may  be  absolute  or  comparative,  and 
the  defects  may  be  in  quality  as  well  as  in  quantity. 

Treatment. — It  is  almost  impossible  to  treat  insomnia 
successfully  unless  the  cause  of  the  sleeplessness  is  known. 
To  discover  the  real  cause  may  be  a  matter  of  no  small  diffi- 
culty, but  the  wise  physician  will  not  treat  the  complaints  of 
his  patients  in  a  haphazard  manner,  merely  trusting  to  good 
fortune  that  the  remedies  he  suggests  may  be  beneficial  in 
bringing  about  a  good  result.  Hypnotics  should  not  be  resorted 
to  until  other  treatment  has  failed.  On  the  other  hand  it  is 
not  wise  to  postpone  giving  sedatives  too  long,  if  other  remedies 
have  failed.  Sleep  is  subtle  in  its  workings  and  cunning  must 
the  physician  be  who  would  induce  it.  The  patient  will  say 
that  he  is  sleepless  in  the  same  way  that  he  will  report  that 
he  has  a  rash,  but  it  is  usually  left  to  the  medical  attendant 
to  say  ivhy  his  patient  does  not  sleep. 

Insomnia  may  be  the  sole  symptom  of  which  the  patient 
complains  and  the  only  reason  for  which  he  seeks  advice.  Such 
a  case  should  be  as  thoroughly  gone  into  as  a  case  of  obscure 
abdominal  disease.  CarefuUy  inquire  into  his  family  history, 
his  past  history,  including  the  various  diseases  from  which 
he  may  have  suffered  ;  learn  the  habits  of  his  life  as  to  food, 
alcohol,  work,  exercise,  clothing,  etc. ;  test  the  various  systems 
of  his  body  ;  in  other  words,  thoroughly  examine  the  man. 

Apart  from  actually  treating  the  sleeplessness  and  its 
causes,  it  is  necessary  to  carry  out  the  treatment  in  such  a 
way  that  the  bad  effects  of  the  insomnia  on  the  mental  and 
physical  health  of  the  patient  are  lessened  as  much  as  possible. 
The  man  that  is  not  sleeping  properly  should  not  attempt  to 
do  the  same  amount  of  work  that  he  was  wont  to  do  when 
in  normal  health.  The  nervous  system  which  has  but 
little  rest  cannot  work  with  impunity  so  quickly  or  so  Jong 
as  when  it  has  time  to  recuperate,  and  this  lack  of  power 
must  be  allowed  for.  Nothing  is  so  harmful  and  dangerous  to 
the  mental  health  as  to  work  with  a  fatigued  nervous  system. 
It  is  under  these  circumstances  that  resort  is  often  made  to 


404  PSYCHOLOGICAL  MEDICINE 

alcohol  and  other  stimulants  in  an  endeavoiu-  to  flog  the 
nervous  system  to  do  more  Avork.  Therefore  be  sure  to  im- 
press on  the  patient  the  dangers  of  sleeplessness  and  the 
importance  of  not  overtaxing  his  strength. 

Further,  it  is  necessary  for  the  man  suffering  from  in- 
somnia to  eat  well,  taking  extra  food  by  night  as  well  as  day. 
If  unable  to  sleep,  light  food,  such  as  milk  and  biscuits,  cocoa, 
etc.,  should  be  taken  during  the  night.  This  will  be  of  great 
assistance  to  the  patient,  for  it  frequently  induces  sleep  ; 
and  even  if  he  remain  wakeful,  it  will  avert  that  sense  of 
faintness  and  feeling  of  exhaustion  which  so  commonly  super- 
vene after  a  sleepless  night.  As  has  already  been  pointed 
out,  the  first  matter  to  be  dealt  with  in  the  treatment  of 
sleeplessness  is  the  regulation  of  the  hfe  and  habits  of  the 
patient,  and  the  following  details  must  be  considered. 

Bedroom,  Clothing,  etc. — The  bedroom  should  be  airy  and 
well  ventilated,  the  temperature  of  the  room  being  regulated  so 
that  it  is  neither  too  hot  in  summer  nor  too  cold  in  winter. 
The  window  should  be  always  open.  The  room  should  be 
situated  in  a  quiet  part  of  the  house  and  away  from  the  noise 
of  any  traffic.  Eemove  all  clocks,  and  wedge  any  windows 
that  may  rattle.  The  mattress  and  pillows  should  be  firm  ; 
feather  beds  should  be  avoided.  The  bed-clothes  should  not 
be  too  heavy,  but  should  be  carefully  regulated  according 
to  the  season  of  the  year.  Excess  of  either  warmth  or  cold 
will  interfere  with  sleep.  The  night  apparel  should  be  very 
light.  No  tight-fitting  under-garments  should  be  worn ; 
in  fact,  vests  are  not  required  at  night.  If  the  patient  suffers 
from  cold  feet,  the  bed  should  be  previously  warmed  by  a 
hot  bottle,  but  this  should  be  removed  before  going  to  sleep. 
There  should  be  no  light  in  the  room  if  this  can  be  avoided. 
This  is  one  of  the  difficulties  in  the  case  of  very  suicidal 
patients,  for  here  it  is  necessary  for  the  nurse  to  be  able  to 
see  her  charge.  Under  these  circumstances,  lights  should  be 
shaded  as  much  as  possible,  and  they  should  never  be 
turned  up  suddenly. 

Diet. — The  diet  should  be  of  a  light  and  nourishing  natm-e. 
Meals  must  be  taken  at  regular  intervals.  The  amount  of 
meat  must  be  limited  in  quantity  ;  the  average  person  eats 
too  much  nitrogenous  foodstuff.     The  drinking  of  milk  should 


SLEEPLESSNESS  405 

be  encouraged,  and  a  tumbler  of  milk  should  be  taken  every 
morning  between  breakfast  and  Imicheon.  The  rule  that  must 
be  laid  down  is  that  the  more  profound  the  insomnia  the 
greater  the  amount  of  food  taken.  Nourishment  must  be  taken 
during  the  night.  Some  persons  require  food  just  prior  to 
retiring  to  bed  ;  others  sleep  better  if  the  meal  is  taken  an 
hour  or  tw^o  earlier.  A  cup  of  hot  gruel  or  bread  and  milk 
taken  in  bed  is  frequently  very  helpful  in  procuring  sleep. 

A  good  deal  may  be  learned  regarding  the  natural  laws  of 
sleep  by  making  a  study  of  the  subject  in  the  lower  animal 
world.  Most  animals  prefer  to  take  a  very  large  meal  and 
then  lay  themselves  down  to  sleep  for  many  hours.  Even 
man,  with  all  his  artificial  habits,  will  be  drowsy  after  a  meal 
and  will  think  less  clearly  than  when  hmigry.  When  food  is 
ingested  the  blood  is  required  in  the  gastric  area,  the  splanchnic 
vessels  are  dilated,  and  there  must  be  a  corresponding  fall 
in  the  vascular  supply  to  the  brain. 

Alcohol. — Some  persons  sleep  better  after  excitants,  others 
after  depressants.  A  bottle  of  stout  or  glass  of  hot  whisky 
and  water  just  before  retiring  to  rest  will  induce  sleep  in  some 
but  increased  wakefulness  in  others.  The  sleepless  man  is 
better  without  alcohol  during  the  day,  and  it  is  wiser  not 
to  have  recourse  to  it  at  night  if  sleep  can  be  obtained  by  other 
means.  It  acts  in  a  similar  v/ay  to  food,  iDut  more  rapidly, 
and  consequently  its  effect  is  more  evanescent.  Alcohol  is  a 
doubtful  friend  to  a  man  with  insomnia  and  should  be  avoided 
if  possible,  as  it  is  apt  to  bring  other  complications  in  its  wake. 
Nevertheless,  in  some  cases  it  is  useful  and  will  sometimes 
relieve  when  everything  else  has  failed  ;  but  such  instances 
are  the  exception  rather  than  the  rule. 

Tobacco. — There  is  httle  doubt  that  tobacco  smoking  when 
carried  to  excess  may  produce  insoimiia.  Since  excess  is  a 
relative  term  and  varies  in  different  individuals,  there  is 
clearly  no  standard  by  wliich  we  can  work.  Cigarette  smoking 
is  a  very  seductive  way  of  consuming  tobacco  and  is  by  no 
means  an  infrequent  cause  of  sleeplessness.  Tobacco  smoking 
of  all  kinds  must  be  regulated  witliin  reasonable  hmits. 

Fatigue. — Mental  or  physical  fatigue  will  readily  produce 
insomnia.  Probably  everyone  has  endured  the  unpleasant 
experience  of  finding  that  upon  retiring  to  bed  after  an  excep- 


406  PSYCHOLOGICAL  MEDICINE 

tionally  tiring  day's  work,  he  is  too  weary  to  sleep.  This 
may  be  the  nightly  condition  of  some  persons.  Extreme 
fatigue  of  tliis  kind  must  be  actively  treated,  otherwise  more 
serious  symptoms  will  certainly  follow.  Whether  the  fatigue 
has  been  produced  by  prolonged  mental  or  bodily  exertion, 
the  only  remedy  is  to  prevent  its  recurrence,  for  it  is  worse 
than  useless  to  treat  the  insomnia  by  drugs  and  leave  the 
cause  uncorrected.  A  hoHday  should  be  taken  rnitil  the  sleep 
has  returned  ;  and  after  employment  has  been  again  started, 
the  number  of  hours  allotted  to  work  and  relaxation  must  be 
regulated.  Another  error  that  some  persons  make  is  to  w^ork 
late  at  night,  and  then  immediately  retire  to  rest  with  the 
brain  in  an  excited  condition.  Such  persons  often  express 
surprise  that  they  cannot  sleep.  All  forms  of  occupation, 
including  games  such  as  chess  and  whist,  for  which  concen- 
trated attention  is  required,  should  cease  at  least  an  hour 
before  bed-time. 

Bowels. — Constipation  is  one  of  the  most  potent  causes 
of  sleeplessness.  In  some  instances  the  mechanical  pressure 
of  an  overloaded  bowel  upon  the  splanchnic  vessels  will 
seriously  interfere  with  the  blood-pressure  of  the  general 
circulation,  and  thus  disturb  the  blood-supply  in  the  brain. 
In  other  cases  the  constipation  may  produce  a  general  auto- 
intoxication, and  the  poisons  circulating  in  the  blood  bring 
about  nutritional  changes  in  the  nerve-cells  in  the  brain. 
Wherever  constipation  is  a  symptom  associated  with  sleepless- 
ness, a  course  of  purgation  is  indicated.  Too  free  action  of 
the  bowels  during  the  day  is  a  common  cause  of  restless  sleep 
at  night,  the  patient  waking  frequently  owing  to  the  peristaltic 
action  of  the  irritable  bowels.  In  these  cases  a  large  dose  of 
Bismuth  Carb.  and  some  Bod.  Bicarb,  acts  as  well  as,  if  not 
better  than,  a  hypnotic. 

Bladder. — Persons  will  sometimes  awake  in  the  early 
hours  of  the  morning  owing  to  the  distended  condition  of 
their  Jjladdcr.  Having  thus  been  aroused,  they  fail  to  get  to 
sleep  again.  In  such  cases  the  amount  of  fluid  imbibed  after 
six  o'clock  in  the  evening  should  be  limited,  for  it  will  be 
found  that  these  patients  will  frequently  sleep  on  several 
hours  longer  if  they  are  not  disturbed. 

Pain — Pyrexia.  —  Any    local    or    general    pain    should    be 


SLEEPLESSNESS  407 

treated.  Pyrexia  very  commonly  produces  sleejDlessness,  and 
as  soon  as  the  fever  is  reduced  the  patient  sleeps. 

Baths. — Hydropathy  is  a  very  useful  mode  of  treatment 
in  some  cases  of  insomnia.  Some  authorities  recommend 
hot  baths  at  bed-time.  This  may  answer  in  some  patients, 
but  in  others  the  effect  produced  is  the  reverse  of  that  desired. 
After  a  hot  bath  there  is  a  reaction,  during  which  the  vessels 
on  the  surface  of  the  body  are  contracted  ;  this  must  br^ng 
about  a  general  rise  of  blood-pressure,  which  defeats  the  end 
in  view.  It  is  more  physiologically  correct  to  give  a  short 
cold  bath  before  retiring  to  rest,  for  if  the  circulation  is  not 
too  weak,  most  patients  get  a  reaction  when  they  get  into 
bed.  The  capillaries  on  the  surface  of  the  body  become  dis- 
tended and  the  blood  is  thus  drawn  from  the  brain,  with  the 
result  that  a  drowsy  sensation  is  experienced.  This  effect 
can  be  enhanced  by  giving  some  warm  food  when  the 
patient  is  in  bed. 

Fixed  Hours  for  Bed-time. — A  point  that  must  not  be  for- 
gotten is  to  order  the  patient  to  retire  to  bed  at  a  regular  hour 
every  night.  Everything  must  be  sacrificed  so  that  this  rule 
can  be  carried  out,  and  no  social  duties  should  be  permitted 
to  interfere  with  it.  Sleep  is  a  habit,  and  when  once  the 
habit  of  going  to  sleep  at  a  certain  hour  has  been  acquired, 
the  custom  should  be  kept  up.  The  hour  for  bed  should  not 
be  later  than  11  p.m.,  and  if  possible  half  an  hour  earlier 
should  be  aimed  at.  Frequent  naps  during  the  day  should  be 
discouraged  ;  in  some  cases  a  short  siesta  after  the  midday 
meal  is  helpful  in  procuring  an  appetite  for  sleep,  but  in  others 
it  will  be  found  to  interfere  with  obtaining  sleep  at  night. 
In  the  latter  case  the  patient  should  be  told  to  rest  for  half  an 
hour  or  an  hour  in  the  early  afternoon,  but  not  to  go  to  sleep. 

Hypnotism. —Hypnotic  suggestion  has  been  found  to  suc- 
ceed in  inducing  sleep  in  some  cases,  where  all  other  methods 
of  treatment  have  failed. 

Hypnotics. — The  subject  of  hypnotics  and  their  use  is  so 
large  a  one  that  it  wih  be  possible  only  briefly  to  review  it. 
The  drugs  which  are  employed  for  the  purpose  of  inducing 
sleep  are  very  numerous,  and  space  will  only  permit  of  reference 
to  those  which  are  in  most  common  use.  When  it  is  deemed 
necessary  to  give  an  hypnotic,  care  should  be  exercised  in 


408  PSYCHOLOGICAL  MEDICINE 

making  the  selection,  as  drugs  of  this  kind  vary  in  suitabiKty 
for  an}^  given  case.  First,  consider  the  patient,  Avhether 
he  is  young  or  old,  rol)Ust  or  feeble,  and  whether  he  is  suffering 
from  any  jDhysical  disease  ;  secondly,  as  to  the  drug,  decide 
whether  the  eti'ect  desired  is  to  be  an  immediate  one  or  whether 
its  action  is  not  required  for  some  hours  ;  and,  finally,  re- 
member that  some  hypnotics  act  as  stimulants,  while  others 
are  depressants. 

Whatever  hypnotic  is  employed,  it  is  not  wise  to  continue 
its  use  too  long.  Its  effect  may  wear  off,  and  it  will  then  act 
rather  as  an  kritant  without  any  corresponding  benefit  in 
producing  sleep  ;  or  if  its  use  is  allowed  to  become  habitual, 
the  patient  may  become  entirely  dependent  upon  the  drug. 

Some  persons  who  have  been  taking  sleeping  draughts  for 
many  weeks  lose  all  confidence  in  their  ability  to  procure  normal 
sleep,  and  if  it  is  suggested  that  their  hypnotic  is  to  be  stopped, 
they  become  very  agitated  and  filled  with  a  feeling  of  dread  that 
they  will  not  sleep.  In  these  cases  it  is  usually  necessary  to 
give  a  placebo,  such  as  a  few^  grains  of  sulphate  of  soda  or  a 
little  aromatic  tinctm-e,  and  the  patient  will  be  found  to  sleep 
as  well  after  taking  this  as  he  was  doing  when  under  the  influ- 
ence of  a  strong  sedative. 

In  conclusion,  never  give  a  patient  a  prescription  for  a 
sleeping  draught  ;  many  lives  are  yearly  lost  by  the  careless 
taking  of  narcotics.  The  timid  sleeper  only  too  readily  forms 
a  habit  of  relying  on  some  sedative  for  his  nightly  rest,  and 
such  a  man  must  be  protected  from  his  own  weakness. 
Hypnotics  are  a  snare  to  some  persons  just  as  alcohol  is  to 
others,  and  the  employment  of  them  should  be  kept  secm'ely 
in  the  hands  of  the  medical  adviser. 

Chloral  Hydrate. — Chloral  hydrate  is  one  of  the  most 
valuable  hypnotics  we  have,  and  it  is  perhaps  not  used  as 
much  as  it  niight  be.  It  is  far  preferable  to  sulphonal  in 
every  way  and  is  not  so  likely  to  give  rise  to  disagi'eeable 
symptoms.  Of  course,  care  must  be  exercised  m  its  use,  as  it 
is  a  powerful  drug  and  belongs  to  the  class  of  cardiac  de- 
pressants. It  is  contra-indicated  in  advanced  cases  of  general 
paralysis  of  the  insane  and  in  patients  suffering  from  severe 
forms  of  heart  disease.  In  all  feeble  persons  it  should  be 
given  in  some  stimulant.     A  mixture  of  chloral  and  bromide 


SLEEPLESSNESS  409 

of  potassiuin  is  almost  better  than  chloral  alone.  It  must  not 
be  forgotten  that  a  chloral  habit  is  somewhat  rapidly  formed, 
consequently  it  is  necessary  to  change  the  draught  from  time 
to  time,  especially  if  the  patient  knows  what  drug  he  is  taking. 
Chloral  hydrate  should  not  be  administered  until  the  patient 
is  in  bed. 

Butyl-chloral  Hydrate.— Butjd-chloral  hydrate  acts  in  a 
similar  way  to  chloral  hydrate,  but  its  action  is  less  powerful 
and  less  certain,  and  it  is  of  little  use  as  an  hypnotic  in  the 
treatment  of  mental  disease. 

Chloralamide. — Chloralamide  is  also  a  disappointing  drug 
in  the  treatment  of  severe  insomnia.  In  those  cases  where 
the  sleeplessness  is  very  profound  chloralamide  is  practically 
useless,  but  in  the  milder  cases  its  effect  is  often  beneficial. 

Bromide  of  Potassium. — In  the  earliest  stage  of  sleepless- 
ness, when  the  patient  is  jcist  becoming  restless  and  is  be- 
giiming  to  lose  confidence  in  his  power  of  sleep,  bromide  of 
potassium  is  a  most  valuable  drug.  Ten  or  fifteen  gi'ains 
given  at  bed-time  has  a  most  extraordinary  effect,  for  it  pro- 
duces a  sense  of  calm,  and  natural  sleep  usually  quickly  super- 
venes. On  the  other  hand,  in  advanced  cases  where  the 
insomnia  is  severe  and  of  long  standing,  bromide  of  potassium 
is  practically  useless  when  given  alone,  but  when  combined 
with  chloral  hydrate  it  makes  a  powerful  narcotic.  When 
given  it  should  be  always  taken  in  plenty  of  water. 

Paraldehyde. — This  drug  has  so  pungent  a  taste  and  so 
disagreeable  an  odour  that  many  patients  will  not  take  it. 
Nevertheless,  it  is  a  valuable  hypnotic  and  is  almost  more 
rapid  in  its  action  than  any  other  narcotic.  In  many  instances 
the  first  time  a  dose  of  two  or  three  drachms  of  paraldehyde 
is  adn-inistered,  the  patient  wall  be  found  to  fall  asleep  within 
two  or  three  m.inutes. 

Paraldehyde  is  a  cardiac  and  respiratory  stimulant  and  is 
useful  for  feeble  persons,  but  it  has  the  disadvantage  that 
it  stimulates  the  secretions  in  the  respiratory  tubes  and 
m&j  lead  to  a  troublesome  form  of  bronchitis.  In  very  acute 
excitement  paraldehyde  can  be  given  in  doses  of  two  and  three 
drachms  twice  a  day.  Paraldehyde  ought  never  to  be  given 
until  the  patient  is  in  bed  and  ready  for  sleep.  A  paralde- 
hyde habit  has  been  known  to  be  formed. 


410  PSYCHOLOGICAL  MEDICINE 

Amylene  Hydrate. — Amyleno  hydrate  is  a  very  valuable 
hypnotic,  as  its  action  is  certain  and  it  seldom,  if  ever,  gives 
rise  to  any  disagreeable  symptoms.  It  is  very  useful  in  the 
treatment  of  insomnia  in  acute  insanity.  The  only  objection 
to  the  drug  is  that  it  is  very  costly,  which  circumstance  some- 
what limits  its  general  use.  As  a  narcotic  it  acts  rapidly 
and  therefore  should  not  be  administered  until  the  patient  is 
in  bed. 

Sulphonal. — Sulphonal  is  probably  one  of  the  most  fre- 
quently used  hypnotics  both  in  private  practice  and  in  in- 
stitutions for  the  insane.  It  is  a  tasteless  and  odourless 
powder,  and  can  for  this  reason  be  easily  administered.  Its 
action  is  slow  but  cum.ulative  and  a  single  dose  will  frequently 
induce  sleep  for  two  nights  in  succession.  Sulphonal  should 
be  given  several  hours  before  its  effect  is  desired.  The  laity 
frequently  take  sulphonal  under  the  impression  that  it  is  a 
harmless  narcotic.  This  is  far  from  being  the  case  and  there 
is  probably  no  hypnotic  so  prone  to  produce  serious  and  dis- 
agi'eeable  symptoms.  Some  persons  may  take  this  drug  for 
a  long  time  with  impunity  ;  others  will  quickly  show  signs  of 
sulphonal  poisoning.  The  earlier  toxic  symptoms  are  weakness 
of  muscles,  inco-ordination  of  gait  and  speech  ;  words  are 
slurred  and  articulation  is  indistinct.  Vomiting  is  not  un- 
common and  it  may  be  accompanied  by  diarrhoea.  Within 
a  short  time  the  urine  becomes  of  a  port-wine  colour.  This 
coloration  is  due  to  hsematoporphyrin,  which  is  an  iron-free 
derivative  of  hsematin.  It  is  present  in  a  minute  quantity  in 
normal  urine.  In  ha^matoporphyrinuria  the  pigment  is  found 
in  large  quantities,  but  the  coloration  of  the  urine  is  by  no 
means  entirely  due  to  the  hajmatoporphyrin,  but  to  some  other 
abnormal  pigments.  Haematoporphyrin  gives  a  very  character- 
istic spectrum.  The  urine  has  also  the  special  quaHty  that 
it  decomposes  very  slowly.  Hsmatoporphyrinuria  is  a  very 
dangerous  symptom  and  many  patients  who  have  it  die 
within  a  fortnight.  Great  care  is  necessary  in  the  administra- 
tion of  sulphonal  and  it  should  not  be  given  continuously  in 
large  doses.  The  bowels  of  a  patient  taking  sulphonal  should 
be  opened  daily,  and  an  aperient  should  be  taken  at  regular 
intervals.  Sulphonal  dissolves  very  slowly,  and  in  cases 
where   the   gastric   secretions   are   diminished  the  hability  to 


SLEEPLESSNESS  411 

poisoning  is  greater.  The  best  way  to  give  sulphonal  is  in 
hot  milk  or  arrowroot. 

Trional.^-Trional  is  very  similar  in  its  action  to  sulphonal, 
but  it  induces  sleep  more  rapidly  and  should  not  be  given 
until  an  hour  before  bed-time.  Trional  is  of  most  value  in 
treating  insomnia  in  the  aged,  but  its  employment  will  be 
found  to  be  disappointing  in  younger  individuals.  The  bad 
effects  of  trional  are  similar  to  those  found  in  sulphonal,  but 
they  occur  less  frequently  and  are  not  so  severe. 

Veronal. — The  hypnotic  action  of  this  drug  is  very  un- 
certain, but  is  good  in  some  cases  and  acts  fairly  rapidly, 
usually  within  an  hour  of  administration.  It  is  useless  in 
treating  those  patients  whose  insomnia  is  caused  by  pain. 
The  dose  varies  from  eight  to  ten  grains  and  the  drug  should 
be  given  in  warm  milk  or  tea. 

Medinal  is  undoubtedly  a  valuable  hypnotic,  especially 
in  early  nerve  exhaustion  states.  It  is  very  soluble  in  water 
and  should  always  be  administered  in  half  a  tumbler  of  water. 
The  dose  is  five  to  ten  grains. 

Luminal  and  Sodium-Luminal  are  also  very  valuable  drugs. 
The  dose  is  five  to  seven  grains. 

Hyoscin  and  Hyoscyamin. — These  drugs  will  be  referred 
to  in  the  general  chapter  on  Treatment.  They  are  useful  in 
some  cases,  but  care  is  required  in  their  administration  and 
a  patient  should  be  in  bed  before  the  drug  is  given. 

Opium,  Morphia,  etc. — Opium  and  its  alkaloids  are  of 
little  use  as  general  hypnotics,  neither  is  it  proper  to 
employ  them  as  such.  There  is  no  drug  which  conduces  to 
forming  a  habit  so  readily  as  morphia,  and  it  is  more  than  an 
error  of  judgment  for  medical  men  to  prescribe  morphia  for 
simple  sleeplessness.  For  insomnia  associated  with  insanity 
morphia  is  of  httle  use,  except  in  those  cases  where  there 
is  extreme  physical  weakness.  For  patients  suffering  from 
severe  mental  and  bodily  exhaustion  its  restorative  powers 
are  greater  than  those  of  any  other  drug. 

Whatever  hypnotic  is  employed,  the  patient  or  whoever 
is  responsible  for  him  must  thoroughly  understand  that  the 
taking  of  a  soporific  is  only  part  of  the  treatment  and  that 
it  in  no  way  lessens  the  importance  of  carrying  out  other 
instructions  as  to  food  and  general  management. 


412  PSYCHOLOGICAL  MEDICINE 


CHAPTER  XXIV 

CASE-TAKING 

A  book  of  this  kind  would  not  be  complete  without  a  few 
remarks  on  the  subject  of  case-taking.  There  are  many 
pitfalls  into  which  the  unwary  may  slip  ;  and  frequently  it 
requires  all  the  wit  and  acumen  of  a  shrewd  physician  to  meet 
the  many  difficulties  which  he  will  have  to  encormter  at  the 
hands  of  both  the  patient  and  his  relatives.  When  first  con- 
sulted the  physician  will  frequently  be  told  that  the  patient  in 
question  is  not  insane  but  merely  unmanageable.  He  will 
also  be  told  that  if  the  patient  even  suspects  that  his  relatives 
think  him  insane  very  serious  results  will  ensue. 

A  physician  known  to  be  specially  versed  in  mental  disorders 
may  be  asked  to  see  the  patient  under  an  assumed  name  or 
under  a  false  pretext.  Never  lend  yourself  to  any  such  duplicity, 
for  if  once  the  patient  finds  you  out  in  any  untruthfuhiess,  your 
influence  has  gone  and  he  will  never  trust  you  again.  The 
stratagems  devised  by  the  patient's  friends  are  often  clumsy 
and  impracticable.  What  physician  having  been  introduced 
as  a  mining  engineer  or  as  a  collector  of  coins  can  hope  to 
engage  successfully  upon  a  minute  inquiry  into  a  patient's 
health  ?  You  may  see  him  unintroduced  and  unannounced, 
but  never  deceive  him  by  false  statements  as  to  your  identity. 

It  is  not  always  possible  to  be  absolutely  truthful  in  a  con- 
versation with  a  patient,  as,  for  instance,  where  he  is  known 
or  believed  to  be  in  possession  of  firearms  or  other  dangerous 
weapons,  for  you  may  have  to  play  the  part  of  the  man's  friend 
and  undertake  to  protect  him  from  his  enemies,  until  assistance 
is  at  hand  and  it  is  possible  to  search  him  and  place  him  under 
care.  Alv>ays  be  ready  with  a  reply,  for  tact  and  quick  wit 
will  greatly  assist  in  dealing  with  insane  persons. 


CASE-TAKING  413 

Eeverting  to  the  topic  under  discussion,  it  not  uncommonly 
occurs  that  the  opinions  of  relatives  may  be  divided  upon  the 
question  of  the  sanity  or  insanity  of  a  patient ;  sometimes 
even  active  resistance  on  the  part  of  individual  relatives  to 
the  attendance  of  the  physician  may  be  encountered.  In 
some  doubtful  cases  of  insanity  the  medical  attendant  may 
be  entirely  misled  by  accepting  a  version  of  the  facts  put 
before  him  by  one  faction.  Eemember  that  this  is  purely  an 
ex  "parte  statement  and  that  it  is  wise  not  to  form  a  judg- 
ment too  rapidly.  If  possible  see  the  opposing  relatives  and 
discuss  the  case  with  them  :  let  them  see  by  your  fairness 
that  your  mind  is  an  open  one  and  that  you  have  in  no  way 
prejudged  the  case.  If  they  are  still  hostile  and  refuse  all 
admittance,  the  question  then  becomes  one  of  law.  The 
Lunacy  Act  provides  for  certain  of  these  difficulties,  for  if  a 
man  is  alleged  to  be  insane  and  is  known  not  to  be  under 
proper  care  and  control,  an  order  can  be  obtained  for  visiting 
this  patient.  In  most  cases  the  obstinate  relative  can  be 
persuaded  to  withdraw  his  opposition  if  sufficient  firmness 
and  tact  are  employed. 

Ultimately,  when  you  see  the  patient,  always  begin  the 
inquiry  by  asking  him  about  his  physical  health,  and  as  openings 
occur,  ask  questions  more  closely  connected  with  his  mental 
state.  Many  patients  will  at  once  discuss  their  delusions  and 
give  a  full  account  of  their  depression  or  fears,  but  with  others 
the  conversation  will  have  to  be  slowly  brought  round  to  the 
topic  in  which  you  are  interested.  Some  individuals  will  refuse 
to  answer  any  questions  relating  to  their  health.  They  will 
tell  you  that  you  are  not  their  medical  attendant  and  that  it 
is  gross  impertinence  on  your  part  to  have  forced  your  presence 
upon  them.  It  may  be  necessary  to  tell  the  patient  that  you 
have  come  to  inquire  into  his  mental  state,  and  that  if  he 
refuses  to  converse  with  you,  you  may  have  to  come  to  the 
conclusion  that  he  is  insane  without  hearing  his  views  on  the 
subject  ;   this  may  produce  the  desired  effect. 

The  man  with  acute  melancholia  or  acute  mania  is  easily 
diagnosed  ;  and  the  person  who  is  very  boastful  and  exalted, 
or  confused  and  stuporose,  is  easily  distinguishable.  The 
greatest  difficulty  is  experienced  in  dealing  with  purely  delu- 
sional cases,  where  there  is  no  apparent  emotional  disturb- 


414  PSYCHOLOGICAL  MEDICINE 

ance,  and  where  the  patient  is  very  much  on  his  guard  during 
the  whole  conversation.  It  may  be  necessary  to  see  the  man 
more  than  once  before  a  decision  can  be  arrived  at.  Eemember 
that  there  are  two  distinct  questions  which  have  to  be  decided  : 
(fl)  Is  the  person  of  unsound  mind  ?  (b)  Is  the  man  a  proper 
subject  to  be  deprived  of  his  hberty  and  detained  under  care 
and  treatment  as  a  person  of  unsound  mind  ?  Many  persons 
are  of  unsound  mind  and  yet  are  quite  fit  to  be  at  large  :  in 
such  cases  there  is  no  reason  why  they  should  be  deprived  of 
their  liberty.     This  topic  is  more  fully  discussed  elsewhere. 

During  the  conversation  with  the  patient,  observe  any- 
thing extraordinary  about  the  dress  or  ornaments  worn  ;  take 
note  of  the  room  and  fm'niture  and  notice  any  peculiarities. 
Some  eccentricity  about  the  attire  or  apartment  may  be  the 
means  of  disclosing  a  delusion.  Nothing  is  too  trivial  to 
note.  Trifling  evidence,  when  proved  to  be  unimportant,  can 
always  be  discarded,  and  sometimes  details  of  seemingly  small 
moment  may  prove  of  great  value  in  forming  a  diagnosis. 
For  the  pm'pose  of  certification,  delusions  are  important, 
but  it  must  not  be  forgotten  that  they  are  rather  a  complica- 
tion than  a  disease,  that  insanity  may  exist  without  them, 
and  that  it  is  necessary  for  many  persons  to  be  deprived  of 
their  liberty  notwithstanding  the  fact  that  no  delusion  can 
be  detected.  For  example,  a  man  may  be  so  depressed  as 
to  be  intensely  suicidal  and  yet  have  no  delusions  ;  or  the 
man  with  an  exaggerated  sense  of  well-being  may  be  grossly 
extravagant  and  yet  entertain  no  false  ideas  of  wealth. 

The  reader  will  do  well  to  study  carefully  the  chapter  on 
General  Symptomatology,  giving  special  attention  to  what 
has  been  said  regarding  delusions  and  hallucinations.  False 
beliefs  so  largely  depend  on  education,  social  status,  and  the 
like,  that  care  must  be  exercised  in  forming  a  judgment  or  too 
readily  accepting  statements  as  delusions. 

Another  point  to  be  borne  in  mind  is  that  the  relatives  of 
the  patient  will  frequently  contend  that  a  particular  belief  is 
not  a  delusion,  as  it  has  a  foundation  in  fact.  But  is  not  this 
true  of  most  delusions  ?  Delusions  may  be  based  on  facts 
and  they  may  have  a  substratum  of  truth.  The  abnormahty 
of  the  condition  is  that  the  truth  is  distorted — that  the  patient 
lays  stress  on  some  small  portion  of  that  truth,  while  totally 


CASE-TAKING  415 

ignoring  other  more  important  factors,  and  consequently 
arriving  at  an  entirely  erroneous  conclusion,  or  at  any  rate  a 
conclusion  which  is  at  variance  with  the  inference  that  the 
majority  of  persons  similarly  situated  would  draw.  Explain 
to  such  a  mistaken  relative  that  the  presence  or  absence  of 
delusions  is  of  small  consequence  compared  with  the  question 
of  the  general  conduct  of  the  patient. 

Again,  it  is  well  to  consider  the  relationship  of  the  person 
who  informs  you  of  the  delusions  of  any  patient  and  to 
observe  the  character  and  temperament  of  the  informant.  For 
example,  is  he  timid  and  easily  frightened.  Is  he  attaching 
undue  importance  to  some  trivial  incident  or  expression  ?  Is 
your  informant  a  husband,  who  has  long  lost  all  affection  for 
his  wife  and  whose  very  antipathy  to  the  woman  he  once 
loved  has  so  blinded  him  that  he  misconstrues  all  her  actions 
into  symptoms  of  insanity  ?  Many  churlish  and  selfish  men 
are  so  brutal  in  their  conduct  to  their  wives  and  children, 
that  it  is  scarcely  to  be  wondered  at  that  medical  men  are 
at  times  called  in  to  examine  their  sanity ;  and  though 
the  physician  may  conclude  that  what  he  sees  and  hears  is 
more  worthy  of  a  degenerate  dement  than  of  a  man  in  full 
possession  of  his  mind,  mere  vicious  degradation  is  not  sufficient 
to  justify  a  certificate  of  mental  unsoundness. 

Insanity  is  a  relative  term,  each  man  is  a  standard  for 
himself,  and  what  would  constitute  insanity  in  one  person  fails 
to  estabhsh  it  in  another.  You  may  be  asked  in  the  courts 
of  justice  whether  swearing  or  profane  language  is  a  proof  of 
mental  disorder.  Like  so  many  other  symptoms,  bad  language 
'per  se  does  not  indicate  mental  disorder  ;  but  when  we  hear 
some  carefully  nurtured  girl  or  pious  priest  burst  out  into 
abusive  and  foul  speech,  this,  taken  with  other  symptoms, 
may  be  an  important  indication  of  the  mental  state  of  that 
person.  Never  hesitate  to  question  a  patient  regarding  his 
delusions,  or  shrink  from  asking  for  an  explanation  of  any 
eccentric  conduct  in  which  he  may  have  been  discovered. 
You  may  tell  him  that  you  do  not  necessarily  beheve  all  that 
you  have  heard  about  him,  but  that  you  are  anxious  to  hear 
what  explanation  he  has  to  give.  Note  whether  the  patient  is 
incoherent  or  inclined  to  wander  in  his  conversation,  or  whether 
he  has  any  peculiar  tricks,  or  is  unduly  fidgety  and  restless. 


416  PSYCHOLOGICAL  MEDICINE 

There  is  nothing  that  calls  for  greater  power  of  observation 
than  the  clinical  examination  of  an  insane  person.  The 
patient  who  is  constantly  turning  his  head  to  one  side  is  not 
uncommonly  listening  to  auditory  hallucinations  ;  the  man 
who  takes  some  appreciable  time  before  answering  questions 
may  be  either  unduly  suspicious  or  generally  confused.  Test 
the  memory,  and  if  it  is  deficient,  find  out  how  long  it  has 
been  failing,  and  whether  the  amnesia  is  an  obstacle  to  the 
patient's  ability  to  look  after  himself  and  his  affairs.  Inquire 
from  the  relatives  and  the  man  himself  whether  there  has 
been  any  change  recently  in  the  latter's  habits,  and  if  so  for 
what  reason.  Eemember  that  many  insane  persons  will  offer 
some  apparently  plausible  reason  for  their  action,  but  when  it 
is  calmly  considered,  it  will  be  found  to  be  flimsy  and  childish. 

Eefusal  of  food  is  an  urgent  symptom,  and  when  it  is  present 
in  any  given  case,  it  behoves  the  medical  attendant  to  investi- 
gate fully  the  reason  why  sufficient  nourishment  is  not  taken, 
and  he  must  be  on  his  guard  against  excuses  unfounded  in 
fact  and  merely  designed  to  mislead. 

A  suicidal  attempt  is  another  point  of  great  importance, 
and  yet  it  is  a  symptom  which  does  not  always  receive  the 
consideration  that  it  deserves.  The  man  who  has  made  an 
attempt  at  self-destruction  is  very  likely  to  repeat  the  experi- 
ment, and  his  second  attempt  may  be  more  successful.  It  has 
already  been  pointed  out  elsewhere  that  the  man  who  has  made 
a  serious  attempt  on  his  fife  is  frequently  better  for  some  time 
afterwards,  and  it  is  usually  at  this  period  that  he  is  visited  by 
the  physician.  If  this  is  the  case,  give  instructions  for  a  careful 
watch  to  be  kept  over  him  day  and  night,  and  examine  him 
again  from  time  to  time  until  you  are  convinced  as  to  his  true 
mental  state.  Frequently  a  good  deal  of  information  can  be 
derived  from  studying  letters  written  by  the  patient.  In  these 
he  may  speak  with  greater  freedom  than  in  conversation, 
and  it  is  well  to  ask  for  permission  to  see  any  recent 
correspondence.  Some  patients,  are  so  clearly  insane  that 
there  is  no  difficulty  in  the  diagnosis,  while  others  require  to 
be  watched  for  a  time  and  visited  more  than  once  before  a 
certificate  can  be  signed. 

Perhaps  one  of  the  greatest  difficulties  is  to  arrive  at  a 
proper   decision   in   the   case   of   feeble-minded    and  morally 


CASE-TAKING  417 

defective  individuals.  In  these  persons  there  is  no  former 
mental  standard  with  which  the  present  state  can  be  com- 
pared ;  the  man  is  not  insane  in  relation  to  his  former 
state.  He  is  merely  lacking  in  certain  mental  attributes 
which  normally  he  ought  to  have  acquired,  and  there  is  no 
definite  period  when  the  relations  first  became  anxious  re- 
garding the  mental  condition  of  the  patient.  As  a  rule  they 
very  gradually  come  to  the  conclusion  that  the  child  or  young 
adult  is  not  quite  what  he  should  be  intellectually.  The 
physician  called  in  to  certify  is  in  a  similar  difficulty.  Although 
every  person  may  have  his  conception  of  the  capabilities 
of  a  normal  mind,  it  is  by  no  means  easy  to  say  at  what 
13oint  below  that  standard  a  person  becomes  so  deficient  as 
to  be  unfit  to  retain  his  liberty.  The  symptoms  upon  which 
a  decision  must  rest  are  in  such  cases  more  negative  than 
positive  ;  it  is  a  failure  of  evolution,  not  dissolution.  There 
are  usually  no  delusions  or  hallucinations. 

On  the  other  hand,  there  may  be  positive  evidence  of  mental 
disorder  in  the  exhibition  of  some  vicious  habits  and  degenerate 
tendencies  ;  but  as  these  are  seldom  shown  during  the  visit 
of  the  physician,  the  latter  is  largely  dependent  for  such  data 
upon  the  statements  of  friends.  Now  the  Lunacy  Act,  1890, 
does  not  permit  of  a  certificate  being  made  merely  on  the 
evidence  of  others,  and  it  is  necessary  for  the  medical  attendant 
to  be  able  to  record  definite  symptoms  of  insanity,  as  observed 
by  himself  during  the  interview  with  the  patient. 

The  past  history  of  a  patient  should  be  thoroughly  gone 
into,  careful  inquiry  being  made  as  to  former  illness  or  serious 
accidents.  The  physician  will  probably  encounter  no  small 
difficulty  in  gleaning  a  true  family  history,  especially  regard- 
ing mental  disorder  in  the  near  relatives  ;  but  ultimately  an 
approximately  accurate  history  can  as  a  rule  be  obtained 
by  asking  questions  of  various  members  of  the  family. 

The  next  point  to  be  considered  is  the  question  of  certifica- 
tion, provided  that  after  a  full  investigation  it  has  been  decided 
to  place  the  patient  under  care,  A  patient  may  be  removed 
under  an  urgency  order  and  one  medical  urgency  certificate. 
The  order  is  made  by  the  nearest  available  relative.  If  no 
relative  can  be  obtained,  a  friend  may  sign  it,  but  the  reason 
why  no  relative  is  acting  must  be  stated.     The  patient  must 

27 


418  PSYCHOLOGICAL  MEDICINE 

have  been  seen  by  this  relative  or  friend  ^vithin  two  days  of  the 
date  of  the  order.  All  names  must  be  -v^Titten  in  full ;  no 
abbreviations  are  permitted.  The  statement  of  particulars  is 
usually  filled  in  by  a  relative,  and  it  is  better  that  it  should 
be  done  by  the  person  who  signs  the  order.  The  urgency 
certificate  is  usually  signed  by  the  regular  medical  attendant. 
FiU  in  the  full  names  and  addresses,  and  in  giving  the  latter, 
state  whether  the  residence  is  in  a  county  such  as  London, 
Surrey,  etc.,  or  in  a  city  or  borough.  Next  state  the  occupa- 
tion of  the  patient,  and  if  the  patient  has  no  occupation,  say 
so,  and  do  not  leave  a  blank  space,  as  this  does  not  necessarily 
indicate  no  occupation,  and  moreover  such  omission  is  not 
accepted  by  the  Board  of  Control. 

The  '  facts  indicating  insanity  observed  at  the  time  of  the 
examination  '  of  the  patient  are  the  next  to  be  entered,  and 
these  form  the  most  important  part  of  the  certificate.  In  the 
first  place,  remember  that  what  you  write  is  in  the  form  of  an 
affidavit  and'  must  be  the  absolute  truth.  Make  yom'  state- 
ments as  short  and  concise  as  possible.  Do  not  state  that  the 
patient  has  '  delusions  '  and  '  hallucinations,'  but  record  w^hat 
these  actually  are.  Some  delusions  are  so  clearly  false  beliefs 
that  no  comment  is  required,  but  with  others  it  may  be  neces- 
sary to  add  a  rider,  such  as,  '  which  I  understand  is  a  delusion.' 
Never  burden  your  certificate  with  unnecessary  matter,  such 
as  a  record  of  physical  symptoms,  as  although  of  the  utmost 
importance  in  diagnosis,  these  are  useless  in  giving  the  mental 
state  of  an  individual.  ^ 

The  second  portion  of  the  certificate,  which  is  composed 
of  '  facts  communicated  by  others,'  need  not  be  filled  in  when 
the  facts  observed  by  yourself  are  strong,  but  in  instances 
where  these  are  weak,  the  certificate  is  greatly  strengthened  by 
being  supported  by  the  evidence  of  others.  Give  the  name 
of  the  informant  in  full  and  his  description  and  address.  In 
an  urgency  certificate  there  is  an  extra  space  provided  in 
which  to  state  the  reasons  why  the  case  is  being  treated  as  an 
urgent  one  and  the  necessity  for  immediate  removal  to  an 
asylum.  Eefusal  of  food,  marked  tendency  to  suicide  or 
violence,  are  among  the  most  common  reasons  for  employing 
urgency  papers,  and  in  all  cases  it  is  necessary  for  the  physician 
to  show  that   the  patient  is  not   imder  proper  control,  and 


CASE-TAKING  419 

that  it  is  expedient  in  the  interest  of  either  the  patient  or  the 
public  that  he  should  be  forthwith  placed  under  care. 

A  person  may  be  detained  under  an  urgency  order  for  seven 
days  from  its  date,  provided  that  the  patient  was  admitted 
into  the  institution  within  two  days  from  the  date  of  the 
examination  by  the  medical  man.  lAHiile  the  urgency  order 
is  in  force,  the  ordinary  statutory  papers  must  be  completed. 
Urgency  orders  can  only  be  used  for  private  patients,  the  law 
being  different  m  the  case  of  paupers. 

Next  may  be  briefly  described  the  ordinary  statutory  forms 
which  consist  of :  (a)  Petition  ;  (&)  Statement  of  Particulars  ; 
(c)  and  (d)  Medical  Certificates  ;  (e)  Keception  Order.  These 
papers  are  absolutely  necessary  for  all  private  patients,  whether 
they  have  been  previously  certified  under  an  urgency  order  or 
not.  The  petitioner,  whenever  possible,  must  be  a  relative,  but 
if  such  is  not  available,  a  friend  may  act,  but  the  reasons  for 
his  doing  so  must  be  stated.  The  petitioner  must  have  seen  the 
patient  within  fom-teen  days  of  the  date  of  the  ^presentation 
of  the  'petition  to  a  judicial  authority.  Care  must  be  taken 
that  no  abbreviations  are  made,  and  that  all  names,  addresses, 
etc.,  are  stated  in  full.  The  statement  of  particulars  ought  to 
be  made  by  a  relative,  and  usually  the  petitioner  signs  it. 
One  of  the  medical  certificates  should  be  signed  by  the  usual 
medical  attendant  of  the  patient,  and  if  from  any  cause  this 
is  not  practicable,  the  petitioner  has  to  state  the  reasons  why 
it  has  not  been  done.  When  a  patient  has  ah'eady  been 
detained  under  an  urgency  order,  the  same  medical  man  who 
has  signed  the  urgency  certificate  can  give  one  of  the  ordinary 
certificates  ;  in  fact,  he  can  copy  word  for  word  his  previous 
certificate  without  again  visitiag  the  patient.  He  must,  how- 
ever, omit  the  special  urgency  clauses.  The  two  medical 
certificates  must  be  written  on  separate  sheets  of  paper,  and 
the  physicians  signing  must  examuie  the  patient  apart  from 
each  other.  The  date  of  the  examination  m  both  instances 
must  not  be  more  than  seven  clear  days  before  the  date  of 
presentation  of  the  petition  to  the  judicial  authority. 

The  following  persons  are  disquahfied  from  signing "  certifi- 
cates :  '  The  petitioner  ;  the  person  signing  the  urgency  order  ; 
the  superintendent,  proprietor,  or  medical  attendant  of  the 
asylum,  hospital  or  house  ;  any  persons  interested  in  the  pay- 


420  PSYCHOLOGICAL  MEDICINE 

ments  or  accounts  of  the  lunatic  ;  or  the  husband  or  the  wife, 
father  or  father-in-law,  mother  or  mother-in-law,  son  or  son- 
in-law,  daughter  or  daughter-in-law,  brother  or  brother-in- 
law,  sister,  or  sister-in-law  ;  partner  or  assistant  of  any  of  the 
foregoing  persons.'  Provision  is  made  in  the  Lunacy  Act, 
1890,  that  persons  signing  medical  certificates  will  not  be 
Hable  to  civil  or  criminal  proceedings  if  they  act  in  good  faith 
and  with  reasonable  care. 

When  the  two  certificates,  the  petition,  and  statement  have 
been  duly  signed,  it  is  then  necessary  to  take  these  forms  and 
present  them  to  a  judicial  authority  specially  appointed  under 
the  Lunacy  Act,  1890,  who  will  give  a  reception  order.  The 
judicial  authorities  are  as  follows  :  (a)  stipendiary  magistrates, 
(fe)  judges  of  county  courts,  and  (c)  justices  specially  ap- 
pointed mider  the  Lunacy  Act,  1890.  The  latter  are  appointed 
amiually  to  serve  for  one  year,  and  their  names  can  always 
be  obtained  by  applying  to  the  clerk  of  the  justices  of  the 
peace.  It  is  not  necessary  to  obtain  the  reception  order  from 
a  judicial  authority  in  the  district  in  which  the  patient  resides, 
though  this  is  advisable  when  possible. 

The  judicial  authority  need  not  see  the  patient  before  he 
gives  the  order,  as  he  can  declare  '  that  he  has  not  personally 
seen  the  patient  before  making  the  order.'     When  a  patient  has 
not  been  personally  seen  by  the  judicial  authority  before  admis- 
sion into  an  institution  or  house,  the  medical  officer  of  the 
same  has  to  give  the  patient  a  form  containing  a  '  notice  of  right ' 
to  a  personal  interview,  or  he  must  certify  to  the  Board  of 
Control  that  '  it  would  be  prejudicial  for  the  patient  to  be 
taken  before  or  visited  by  a  stipendiary  magistrate,  county 
court  judge,  or  justice  of  the  peace.'     When  a  reception  order 
has  been  given,  the  patient  must  be  received  into  the  asylum 
or  house  within  seven  clear  days  from  the  date  of  the  order, 
otherwise  the  order  expires  ;   and  it  will  then  be  necessary  for 
all  the  papers  (petition,  statement,  and  two  certificates)  to  be 
filled  in  afresh  before  a  new  reception  order  can  be  applied  for. 
Li  the  case  of  pauper  patients  the  law  is  different,  and  the 
simplest  method  of  procedure  is  for  the  friends  of  the  patient 
to  inform  the  relieving  officer  of  the  district  in  which  they 
live  that  they  have  a  relative  who  is  insane  and  who  is  not 
under  proper  control.     The  relieving  officer  then,  as  a  rule, 


CASE-TAKING  421 

removes  the  man  to  the  workhouse  infirmary,  where  he  may 
reside  for  ten  days  under  the  supervision  of  the  medical  officer, 
and  from  thence  he  is  drafted  into  the  county  or  borough 
asylum. 

At  times  a  difficulty  arises  in  the  case  of  a  person  in  ap- 
parently good  circumstances,  as  the  relieving  officer  may  state 
that  the  case  is  not  proper  for  his  interference.  The  law 
does  not  respect  any  such  difference,  and  the  Lunacy  Act 
provides  that  '  every  constable  and  relieving  officer,  and  every 
overseer  of  a  parish,  who  has  knowledge  that  any  person 
(whether  a  pauper  or  not)  wandering  at  large  within  the  dis- 
trict or  parish  of  the  constable,  relieving  officer,  or  overseer, 
is  deemed  to  be  a  lunatic,  shall  immediately  apprehend  and 
take  the  alleged  lunatic,  or  cause  him  to  be  apprehended  and 
taken  before  a  justice.'  '  Wandering  at  large  '  means  not  under 
proper  care  and  control.  The  rich  as  well  as  the  poor  can  be 
treated  under  this  section,  and,  in  point  of  practice,  the  above 
provision  may  be  the  only  or  the  best  way  of  securing  a  patient 
who  is  dangerous  or  difficult  to  find.  Clearly  it  is  not  proper 
to  send  a  man  with  ample  means  to  an  asylum  where  he  will 
have  to  associate  with  paupers,  nor  does  the  law  allow  a 
justice  to  do  this  if  he  is  aware  that  a  man  is  not  a  pauper. 
The  patient  can  be  certified  as  a  private  patient  at  the  infirmary 
and  removed  thence  to  a  hospital  or  licensed  house,  or  even 
after  removal  to  a  county  asylum  he  can  be  transferred  to  a 
more  suitable  place. 

For  the  convenience  of  practitioners,  the  sections  in  the 
Lunacy  Act  dealing  with  '  Summary  Eeception  Orders  '  are 
here  given. 

SuMMAEY  Eeception  Orders.     Lunacy  Act,  1890, 
Sects.  13-23 

'  13. — (1)  Every  constable,  relieving  officer,  and  overseer 
of  a  parish,  who  has  knowledge  that  any  person  within  the 
district  or  parish  of  the  constable,  relieving  officer,  or  overseer, 
who  is  not  a  pauper  and  not  wandering  at  large,  is  deemed  to 
be  a  lunatic,  and  is  not  under  proper  care  and  control,  or  is 
cruelly  treated  or  neglected  by  any  relative  or  other  person 
having  the  care  or  charge  of  him,  shall  within  three  days  after 
obtaining  such  knowledge  give  information  thereof  upon  oath 
to  a  justice  being  a  judicial  authority  under  this  Act. 


422  PSYCHOLOGICAL 'medicine 

(2)  Any  such  justice,  upon  the  information  on  oath  of 
any  person  whomsoever,  that  a  person  not  a  pauper,  and  not 
wandering  at  large,  is  deemed  to  be  a  lunatic  and  not  under 
proper  care  and  control,  or  is  cruelly  treated  or  neglected  as 
aforesaid,  may  himself  visit  the  alleged  lunatic,  and  shall, 
whether  making  such  visit  or  not,  direct  and  authorise  any 
two  medical  practitioners  whom  he  thinks  fit  to  visit  and 
examine  the  alleged  lunatic,  and  to  certify  their  opinion  as  to 
his  mental  state,  and  the  justice  shall  proceed  in  the  same 
manner  so  far  as  possible,  and  have  as  to  the  alleged  lunatic 
the  same  powers,  as  if  a  petition  for  a  reception  order  had 
been  presented  by  the  person  by  whom  the  information  with 
regard  to  the  alleged  lunatic  has  been  sworn. 

'  (3)  If  upon  the  certificates  of  the  medical  practitioners 
who  examine  the  alleged  lunatic,  or  after  such  other  and 
further  inquiry  as  the  justice  thinks  necessary,  he  is  satisfied 
that  the  alleged  lunatic  is  a  lunatic,  and  is  not  under  proper 
care  and  control,  or  is  cruelly  treated  or  neglected  by  any 
relative  or  other  person  having  the  care  or  charge  of  him, 
and  that  he  is  a  proper  person  to  be  taken  charge  of  and 
detained  under  care  and  treatment,  the  justice  may  by  order 
direct  the  lunatic  to  be  received  and  detained  in  any  institu- 
tion for  lunatics  to  which,  if  a  pauper,  he  might  be  sent  under 
this  Act,  and  the  constable,  reheving  officer,  or  overseer 
upon  whose  information  the  order  has  been  made,  or  any 
constable  whom  the  justice  may  require  so  to  do,  shall  forth- 
with convey  the  lunatic  to  the  institution  named  in  the  order.' 

[L.A.,  1891,  sect.  3. — A  lunatic  sent  to  an  institution  for 
lunatics  under  sections  13  or  16  of  the  principal  Act  shall 
be  classified  as  a  pauper,  until  it  is  ascertained  that  he  is 
entitled  to  be  classified  as  a  private  patient.] 

'  14. — (1)  Every  medical  officer  of  a  union,  who  has  know- 
ledge that  a  pauper  resident  within  the  district  of  the  officer 
is  or  is  deemed  to  be  a  lunatic  and  a  proper  person  to  be  sent 
to  an  asylum,  shall,  mthin  three  days  after  obtaining  such 
knowledge,  give  notice  thereof  in  writing  to  the  relieving  officer 
of  the  district,  or  if  there  is  no  such  officer,  to  an  overseer  of 
the  parish  where  the  pauper  resides. 

'  (2)  Every  reheving  officer  and  every  overseer  of  a  parish 
of  which  there  is  no  relieving  officer,  who  respectively  has 
knowledge,  either  by  notice  from  a  medical  officer  or  otherwise, 
that  any  pauper  resident  within  the  district  or  parish  of  the 
reheving  officer  is  deemed  to  be  a  lunatic,  shall,  witliin  three 


CASE-TAKING  423 

days  after  obtaining  such  knowledge,  give  notice  thereof  to 
a  justice  having  jurisdiction  m  the  place  where  the  pauper 
resides. 

'  (3)  A  justice,  upon  receiving  such  notice,  shall  by  order 
require  the  relieving  officer  or  overseer  giving  the  notice,  to 
bring  the  alleged  lunatic  before  him  or  some  other  justice 
having  jurisdiction  in  the  place  where  the  pauper  resides,  at 
such  tirne  and  place  within  three  days  from  the  time  of  the 
notice  to  the  justice  as  shall  be  appointed  by  the  order. 

'  15. — (1)  Every  constable  and  relieving  officer  and  every 
overseer  of  a  parish  who  has  knowledge  that  any  person  (whether 
a  pauper  or  not)  wandering  at  large  within  the  district  or 
parish  of  the  constable,  relieving  officer,  or  overseer  is  deemed 
to  be  a  lunatic,  shall  immediately  apprehend  and  take  the 
alleged  lunatic,  or  cause  him  to  be  apprehended  and  taken, 
before  a  justice. 

'  (2)  Any  justice,  upon  the  information  upon  oath  of  any 
person  that  a  person  wandering  at  large  within  the  limits  of 
his  jurisdiction  is  deemed  to  be  a  lunatic,  may  by  order  re- 
quire a  constable,  relieving  officer,  or  overseer  of  the  district 
or  parish  where  the  alleged  lunatic  is,  to  apprehend  him  and 
bring  him  before  the  justice  making  the  order,  or  any  justice 
having  jurisdiction  where  the  alleged  lunatic  is. 

'  16. — The  justice  before  whom  a  pauper  alleged  to  be  a 
lunatic  or  an  alleged  lunatic  wandering  at  large  is  brought 
under  this  Act  shall  call  in  a  medical  practitioner,  and  shall 
examine  the  alleged  lunatic,  and  make  such  inquiries  as  he 
tliinks  advisable,  and  if  upon  such  examination  or  other  proof 
the  justice  is  satisfied  in  the  first  mentioned  case  that  the 
alleged  lunatic  is  a  lunatic  and  a  proper  person  to  be  detained, 
and,  in  the  secondly  mentioned  case,  that  the  alleged  lunatic 
is  a  lunatic,  and  was  wandering  at  large,  and  is  a  proper 
person  to  be  detained,  and  if  in  each  of  the  foregoing  cases  the 
medical  practitioner  who  has  been  called  in  signs  a  medical 
certificate  with  regard  to  the  lunatic,  the  justice  may  by  order 
direct  the  lunatic  to  be  received  and  detained  in  the  institution 
for  lunatics  named  in  the  order,  and  the  relieving  officer, 
overseer,  or  constable  who  brought  the  lunatic  before  the 
justice,  or  in  the  case  of  a  lunatic  wandering  at  large,  any 
constable  who  may  by  the  justice  be  required  so  to  do,  shall 
forthwith  convey  the  lunatic  to  such  institution. 

'  17. — Where,  under  this  Act,  notice  has  been  given  to,  or 
an  information  upon  oath  laid  before  a  justice  that  a  pauper 


424  PSYCHOLOGICAL  MEDICINE 

resident  ■v\dtliin  the  limits  of  his  jurisdiction  is  deemed  to  be  a 
lunatic,  and  a  proper  person  to  be  sent  to  an  asylum,  or  that 
a  person,  whether  a  pauper  or  not,  wandering  at  large  within 
the  limits  aforesaid,  is  deemed  to  be  a  lunatic,  such  justice 
may  examine  the  alleged  lunatic  at  his  own  house  or  else- 
where, and  may  proceed  in  all  respects  as  if  the  alleged  lunatic 
had  been  brought  before  him. 

'  18. — A  justice  shall  not  sign  an  order  for  the  reception  of 
a  person  as  a  pauper  lunatic  into  an  institution  for  lunatics 
or  workhouse,  unless  he  is  satisfied  that  the  alleged  pauper  is 
either  in  receipt  of  relief  or  in  such  circumstances  as  to  re- 
quire reUef  for  his  proper  care.  If  it  appears  by  the  order 
that  the  justice  is  so  satisfied  the  lunatic  shall  be  deemed  to 
be  a  pauper  chargeable  to  the  union,  county,  or  borough 
properly  liable  for  his  relief.  A  person,  who  is  visited  by  the 
medical  officer  of  the  union,  at  the  expense  of  the  union,  is, 
for  the  purposes  of  this  section,  to  be  deemed  to  be  in  receipt 
of  relief. 

'  19. — (1)  A  justice  making  an  order  for  the  reception  of  a 
lunatic  other-v\dse  than  upon  petition,  in  this  Act  called  a 
"  summary  reception  order,"  may  suspend  the  execution  of  the 
order  for  such  period  not  exceeding  fourteen  days  as  he  thinks 
fit,  and  in  the  meantime  may  give  such  directions  or  make 
such  arrangements  for  the  proper  care  and  control  of  the 
lunatic  as  he  considers  proper. 

'  (2)  If  a  medical  practitioner  who  examines  a  lunatic  as  to 
whom  a  summary  reception  order  has  been  made,  certifies  in 
%\Titing  that  the  lunatic  is  not  in  a  fit  state  to  be  removed,  the 
removal  shall  be  suspended  until  the  same  or  some  other  medical 
practitioner  certifies  in  writing  that  the  lunatic  is  fit  to  be 
removed,  and  every  medical  practitioner  who  has  certified  that 
the  lunatic  is  not  in  a  fit  state  to  be  removed  shall,  as  soon  as 
in  his  judgment  the  lunatic  is  in  a  fit  state  to  be  removed,  be 
bound  to  certify  accordingly. 

'  20. — If  a  constable,  relieving  officer,  or  overseer  is  satisfied 
that  it  is  necessary  for  the  public  safety  or  the  welfare  of  an 
alleged  lunatic  with  regard  to  whom  it  is  his  duty  to  take  any 
proceedings  under  this  Act,  that  the  alleged  lunatic  should, 
before  any  such  proceedings  can  be  taken,  be  placed  under  care 
and  control,  the  constable,  relieving  officer,  or  overseer  may 
remove  the  alleged  lunatic  to  the  workhouse  of  the  union  in 
w^hich  the  alleged  lunatic  is,  and  the  master  of  the  workhouse 


CASE-TAKING  425 

shall,  unless  there  is  no  proper  accommodation  in  the  work- 
house for  the  alleged  lunatic,  receive  and  relieve  and  detain 
the  alleged  lunatic  therein,  but  no  person  shall  be  so  detained 
for  more  than  three  days,  and  before  the  expiration  of  that 
time  the  constable,  reheving  officer,  or  overseer  shall  take  such 
proceedings  with  regard  to  the  alleged  lunatic  as  are  required 
hj  this  Act. 

'  21. — (1)  In  any  case  where  a  summary  reception  order 
might  be  made,  any  justice,  if  satisfied  that  it  is  expedient  for 
the  welfare  of  the  lunatic,  or  for  the  pubhc  safety,  that  the 
lunatic  should  forthwith  be  placed  under  care  and  control, 
and  if  it  appears  to  him  that  there  is  proper  accommodation 
for  the  lunatic  in  the  workhouse  of  the  union  in  which  the 
lunatic  is,  may  make  an  order  for  taking  the  lunatic  to  and 
receive  him  in  that  workhouse. 

'  (2)  In  any  case  where  a  summary  reception  order  has  been 
made,  an  order  under  this  section  may  be  made  to  provide  for 
the  detention  of  the  lunatic  until  he  can  be  removed. 

'  (3)  An  order  under  this  section  shall  not  authorise  the 
detention  of  a  lunatic  in  a  workhouse  for  more  than  fourteen 
days.  After  which  period  such  detention  shall  not  be  lawful, 
except  in  accordance  with  the  provisions  of  this  Act  as  to  the 
detention  of  lunatics  in  workhouses. 

'  (4)  An  order  under  this  section  may  be  made  by  any  justice 
having  jurisdiction  in  the  place  where  the  lunatic  is. 

'  22. — In  the  case  of  a  lunatic  as  to  whom  a  summary  re- 
ception order  may  be  made,  nothing  in  this  Act  shall  pre- 
vent a  relation  or  friend  from  retaining  or  taking  the  lunatic 
under  his  own  care  if  a  justice  having  jurisdiction  to  make 
the  order,  or  the  visitors  of  the  asylum  in  which  the  lunatic 
is,  or  is  intended  to  be  placed,  shall  be  satisfied  that  proper 
care  will  be  taken  of  the  lunatic. 

'  [L.A.,  1891,  sect.  2. — (1)  A  constable,  reheving  oflficer,  or 
overseer,  whose  duty  it  is,  under  the  principal  Act,  to  convey 
a  lunatic  to  or  from  an  institution  for  lunatics,  may  make 
proper  arrangements  for  the  performance  of  the  duty  by  some 
other  person  or  persons. 

'  (2)  Where  in  a  union  there  are  two  or  more  reheving  officers, 
and  the  guardians,  with  the  sanction  of  the  Local  Government 
Board,  direct  one  reheving  officer  to  discharge  throughout 
the  union  the  duties  of  a  reheving  officer,  in  respect  of  lunatics, 
every  other  relieving  officer  in  the  union  shall  inform  the  officer 


426  PSYCHOLOGICAL  MEDICINE 

SO  directed  of  any  case  of  a  lunatic,  with  which  it  would  other- 
wise devolve  upon  such  other  reheving  of&cer  to  deal,  and  it 
shall  be  the  duty  of  the  relieving  officer  receiving  such  informa- 
tion to  deal  with  the  case,  and  the  other  relieving  officer  shall 
be  discharged  from  any  further  duty  in  the  matter.] 


Beceftion  Order  by  two  Commissioners 

'  23. — (1)  Any  two  or  more  Commissioners  may  visit  a 
pauper  lunatic  or  alleged  lunatic  not  in  an  institution  for 
lunatics,  or  workhouse,  and  may,  if  they  think  fit,  call  in  a 
medical  practitioner. 

'  (2)  If  the  medical  practitioner  signs  a  medical  certificate 
with  regard  to  the  lunatic,  and  the  Commissioners  are  satisfied 
that  the  pauper  is  a  lunatic,  and  a  proper  person  to  be  de- 
tained, they  may  by  order  direct  the  lunatic  to  be  received  in 
an  institution  for  lunatics,  and  the  relieving  officer  of  the  dis- 
trict or  any  constable  who  may  by  them  be  required  so  to  do 
shall  forthwith  convey  the  lunatic  to  such  institution.'^    ;    ; 

In  conclusion,  the  following  scheme  for  the  general  examina- 
tion of  the  patient  may  be  found  useful : 

I.  Inquire  concerning  the  life  liistory  of  the  fatieiit — 

(a)  Changes  of  cHmate  and  places  of  residence. 
(&)  Nature  of  work. 

(c)  Food  and  stimulants.     Alcohol  and  other  drugs. 

(d)  Marriage — number  of  children. 

(e)  Home  comfort  or  privation. 

(/)  At  what  age  did  patient  walk,  speak,  etc.? 

{g)  Degree  and   character   of   education,   and   whether 

he    was    slow    or    quick    at    learning    when    a 

child. 
{h)  Character  and  temperament'  in  childhood, 
(i)  tSleop  ;  whether  it  has  always  been  good,  or  whether 

defective  or  abnormal  in  any  way  (sleep-walking 

and  sleep-talking). 
(k)    Special  sense-defects,  blind,  deaf,  etc. 
(1)    Defects  of  speech  from  childhood,  stammering,  etc. 
[m)  Sexual  relation. 


CASE-TAKING  427 

If  a  woman,  inquire — 

(a)  First  appearance  and  regularity  of  catamenia. 

(6)  If  married,  number  and  date  of  pregnancies,  and 

whether     any     miscarriage  ;      also     health     of 

children. 

II.  Family  history  of  hlood  relations  only — 

Check  the  patient's  statements   by  inquiring  into 

chief  symptoms  of  any  disease  that  is  reported. 

(a)  Insanity  or  definite  mental  peculiarities,  including 

idiocy  and  imbecility. 
(6)  Epilepsy,  both  minor  and  major  forms. 

(c)  Alcoholism. 

(d)  Drug  habits. 

(e)  Phthisis. 
(/)  Diabetes. 

(g)  Gout,  rheumatism,  heart  disease. 

(h)  Malignant  disease. 

(i)   Syphilis. 

(k)  Asthma,  stammering,  hysteria,  etc. 

III.  Previous  history  regarding  illnesses  and  accidents  to  the 
patient — 

(a)  Convulsions  in  childhood  or  later. 

(h)  What  diseases  he  has  had,  especially  such  as  syphilis, 
signs  of  phthisis,  diabetes,  hysteria,  previous 
attacks  of  mental  disorder,  rheumatic  fever, 
chronic  dyspepsia,  chronic  constipation,  etc. 

(c)  Sunstroke. 

{d)  Serious  accidents,  and  whether  loss  of  conscious- 
ness. 

Take  careful  notes  of  the  dates  of  any  of  the  above. 
IV.  Supposed  or  assigned  cause  of  present  illness. 


428  PSYCHOLOGICAL  MEDICINE 

V.  Present  illness. 

Note  carefully  the  order  of  occurrence  of  symptoms, 
especially  those  which  first  arrested  the  friends'  or  patient's 
attention.  Then  inquii'e  for  any  other  symptoms  that  may 
have  preceded  these,  but  have  passed  unnoticed. 

1.  Physical  condition.     General  appearance. 

(a)  Weight  and  nutrition. 

(b)  Expression  and  attitude. 

(c)  Stigmata  of  degeneration. 

(d)  Gastro-intestinal  tract  ;   refusal  of  food. 

(e)  Heart  and  vascular  system, 
(/)  Eespiratory  system. 

(g)  Genito-m'inary  system  ;   catamenia. 
{h)  Skin  and  appendages. 
(i)  Nervous  system. 

(1)  Motor    symptoms,    paresis,    paralysis    or    dis- 

ordered movements,   gait,   convulsions. 

(2)  Sensory  symptoms,  hypersesthesia,  anaesthesia, 

analgesia,  paraesthesia. 

(3)  Special  sense   sensations,    disorders   of   sight, 

hearing,  smell,  taste,  and  field  of  vision. 

(k)  Pupillary  changes — 

(1)  Size. 

(2)  Mobility. 

(3)  Inequality. 

(4)  Reflex  f    (i)  Consensual  reflexes. 

adjustments  \    (ii)  Reflex-iridoplegia. 

i  (iii)  Sympathetic  reflexes. 

(5)  Accommodative  adjustments. 

(1)  Tendon    reflexes.     Knee-jerks,    plus,    minus,    lost, 

or  different  on  the  two  sides. 
{m)  Superficial  reflexes. 


CASE-TAKING  429 

(n)  Speech  disorders, 
(o)  Sleep. 

(p)  Lumbar  puncture,  when  in  doubt  as  to  the  case 
being  one  of  general  paralysis. 


2.  Mental  condition. 

(a)  Mood.  Unduly  excited,  depressed,  exalted,  irrit- 
able, hostile,  suspicious,  quarrelsome,  indolent, 
apathetic,  emotional. 

(&)  ^Esthetic  sentiment.  Disordered,  untidy,  unwashed, 
hair  dishevelled,  decorated. 

(c)  Sensation  and  Perception. 

(d)  Attention.     Easily  distracted,  inattention  or  hyper- 

attention. 

(e)  Conduct.     Eestless,     eccentric,      attends     to     calls 

of  nature,   dresses  himself,  noisy  or  abnormally 

quiet. 
(/)  Memory.    Amnesia    for   recent    or    distant    events, 

hypermnesia  or  paramnesia. 
{g)  Orientation  as  to  time  and  place.     Is  the  patient 

capable    of    locaHsing    himself    and    objects    and 

persons  about  him  ?   Does  he  mistake  identity  ? 
Qi)  Mode    of    speech.     Slow,     accelerated,     mute    or 

incoherent. 
[i)  Judgment   and  reasoning  power.     Does  he  reahse 

that    he    is    ill,    and    how    does    he    explain    his 

illness  ? 
{j)  Occupation.     Does   he   employ   his   time   in   doing 

reasonable  things,  or  is  he  entirely  unoccupied  ? 
(k)  Delusions.  ' 
{I)    Imperative  ideas. 

(m)  Hallucinations  or  illusions  of  any  special  sense, 
(w)  Suicidal, 
(o)  Homicidal. 

The  following  are  copies  of  an  urgency  medical  certificate 
and  an  ordinary  medical  certificate  : 


430  PSYCHOLOGICAL  MEDICINE 


Urgency  Certificate. 

53  Vict.  c.  5. — Sched.  2,  Form  8. 
CERTIFICATE  OF  MEDICAL  PRACTITIONER. 


Ju  the  matter  of 


(a)  Insert  residence    of    of  fa) 
patient. 

(6)  County,     city,    or   in  the  {b) of 

borough,  as  the  case  may 
be. 


(c) 


(c)  Insert  profession  or  ..        _  , 

occupation,  if  any.  an  alleged  lunatic. 


I,  the  undersigned 

do  hereby  certify  as  follows  : 

1.  I  am  a  person  registered  under  the  Medical  Act  1858,  and 
I  am  in  the  actual  practice  of  the  medical  profession. 

2.  On  the    day  of 19     , 


(d)  Insert  the  place  of  ^^  /^^-j 
examination,    giving    the  ^ 

name   of  the   street,    with  •      i-u      /   \  „f 

number  or  name  of  house,  ^^  tne  \(i)    01     

or  should  there  be  no  nnm- 

bfT,the  Christian  and  sur-   I  personally  examined  the  said 

name  of  occupier. 

(c)  County,    city,    or   and  came  to  the  conclusion  that  he  is  (/) 

borough,  as  the  case  may 

be.  and  a  proper  person  to  be  taken  charge  of  and  detained  under 

(f)  A  lunatic,  an  idiot,    care  and  treatment. 
or  a  person  of  unsound 

mind. 

3.  1  formed  this  conclusion  on  the  following  grounds,  viz.  : — 

(g)  If  the  same  or  other  («.)  Facts  indicating  Insanity  observed  by  myself  at  the  time 
facts   uere   observed   pre- 
vious to  the  time  of  the     £  examination  {g),  viz.  : 

examination,  the  certifier  ^^ " 

M    at   liberty   to   subjoin 

them  in  a  separate  para 

graph. 


(h)  The    names     and       tf^)  pacts  communicated  by  others  (h),  viz. 
Christian       names        (if         ^     ' 
known)  of  informants  to 

be  given,   with  their  ad-     

dresses  and  descriptions. 


LUNACY  NOS.  8  &  9. 


(.53  Vict.  c.  5,  ss.  11, 
23,  29,  32  &  33.) 


CASE-TAKING  431 


53  Vict.  c.  5.     Form  9. 


0")  II  an  urgency  cctHH-       (0  STATEMENT  ACCOMPANYING  URGENCY  ORDER. 
cate  is  required,  it  must  be 
added  here. — FormJVo.  9. 


3"  certify  that  it  is  expedient  for  the  welfare  of  the  said 

[or  for  the  public  safety, 

as  the  case  may  be]  that  the  said    

should  be  forthwith  placed  under  care  and  treatment. 

My  reasons  for  this  conclusion  are  as  follows  : 


] 


4.  The  said 

appeared  to  me  to  be  [or  not  to  be]  in  a  fit  condition  of  bodily 

(/■;)  Strike  out  this  clause  health  to  be  removed  to  an  asylum,  hospital,  or  licensed  house,  {h) 
in  case  nf  a  private  patient 

whose    removal     is    not  g    j  ^j^g  ^j^jg  certificate  having  first  read  the  section  of  the 

proposed.  '-' 


Act  of  Parliament  printed  below. 

H)atCD  this day  of    . . 

One  Thousand  Nine  Hundred  and 


(D  Insert     full    postal 
address. 


(SfgneD) 

of  (Z)  . . 


Extract  from  section  317  of  the  Lunacy  Act  1890. 
r  Any  person  who  makes  a  wilful  misstatement  of  any  material 
fact  in  any  medical  or  other  certificate,  or  in  any  statement  or 
report  of  bodily  or  mental  condition  under  this  Act,  shall  be 

guilty  of  a  misdemeanour. 

[Continued  over.] 


432  PSYCHOLOGICAL  MEDICINE 


53  Vict.  c.  5. — Sched.  D,  Foem  8. 
CERTIFICATE  OF  MEDICAL  PRACTITIONER. 


3-n  the  matter  of 

(a)  Insert  residence  of    of  (a)    

patient  in  the  (6) 

(6)  County,     city,     or 

borough,  as  the  case  may  (c)    

be. 

,  ,  .    _       ,     .  an  alleged  lunatic, 
(c)  Insert  profession  or  ° 

occuvalion,  if  any.  t    j  i  i       ■         i 

I,  the  undersigned,    

do  hereby  certify  as  follows  : 

1.  I  am  a  person  registered  under  the  Medical  Act   1858, 
and  I  am  in  the  actual  practice  of  the  medical  profession. 

2.  On  the    day  of    191  , 

(fl)  Insert  the  -place  of  „*.  ij\ 

examination,    ijiviruj    the  ^   ' 

name  of  the  street,    icith   in  the  (e) of 

niLmber  or  name  of  house, 

or  should  there  be  no  nvm-  (separately    from    any    other    pract/itioner)     (/)    I    personally 

ber,    the    Christian    and  .       ,   ., 

Surname  of  occupier.  examined  the  sa.id    


of  examination  {h),  viz. 


(e)  County,     city,    or   and  came  to  the  conclusion  that  he  is  (^)    

borough,  as  the  case  may 

be.  and  a  proper  person  to  be  taken  charge  of  and  detained  under 

(/)  Omit    this     where  ^are  and  treatment. 
only  one  certi/:cate  is  re- 

^'"'"^  ■  3.  I  formed  this  conclusion  on  the  following  grounds,  viz. : 

('/)  A  lunatic,  an  idiot,  .  . 

or  a  person  ol  unsound  (a.)  Facts  indicating  Insanity  observed  by  myself  at  the  time 
mind. 

(h)  If  the  same  or  other 

facts   were   observed   pre-    

vious  to  the  time  of  t/te 

examination,  the  certijler    

is   at   liberty   to    subjoin 

them  in  a  separate  para-        (6.)  Facts  communicated  by  others  {i),  viz. 

graph. 

(i)  The      names      and 

Christian       names       (if    

Icnown)  of  informants  to 

tJ!''!'!:.:^:^!tJ!'!L!^'         4.  The  said  


dresses  and  descriptions. 
»  Or  not  to  be.  appeared  to  me  to  be  * in  a  fit  condition  of  bodily 

{k)Strih-eout  this  clause   health  to  be  removed  to  an  asylum,  hospital,  or  licensed  house,  {k) 
in  case  of  a  patient  wlwse 
removal  is  not  proposed.  5.  I  give  this  certificate  having  first  read  the  section  of  the 

Act  of  Parliament  printed  below. 

(SlGiieD) 

(1)  Insert     full     postal                              i  ,]. 
address.  °^  ^'/ 

DateO  this day  of 191 . . 


Any  person  who  makes  a  wilful  misstatement  of  any  material 
LUNACY  8.  fact  in  any  medical  or  other  certificate,  or  in  any  statement  or 

_.  report  of  bodily  or    mental  condition  under  this  Act,  shall  be 

(03   \  ict    c.   5,   ss.    i ,  guilty  of  a  misdemeanour. — Extract  from  section  317  of  the  Lunacy 
'■'''■'  Act  1890. 


433 


CHAPTEE  XXV 

TREATMENT 

In  the  opening  sentence  of  the  chapter  on  the  treatment  of 
mental  disease,  let  us  urge  upon  the  student  to  approach  this 
important  subject  in  the  same  way  that  he  would  take  up  the 
study  of  treatment  in  physical  disease.  Insanity  is  one  of  the 
common  ills  of  humanity.  It  is  gratifj^ing  to  be  able  to  beHeve 
that  pubhc  opinion  has  almost  outgrown  that  era  of  ignorance 
in  which  the  mentally  afflicted  were  looked  upon  as  lepers  and 
outcasts,  as  beings  whose  disease  and  almost  whose  very  names 
should  be  forgotten  or  mentioned  only  with  bated  breath. 

Insanity  is  not  a  crime,  unless  all  disease  be  deemed  to  be 
the  natural  sequel  of  primal  sin,  the  blame  for  which  may 
be  justly  attributed  to  the  individual  sufferers  in  succeeding 
generations.  Lisanity  is  no  crime,  but  a  grievous  misfortune. 
Occasionally,  without  doubt,  insanity  is  earned  by  a  profUgate 
and  misspent  hfe,  an  observation  equally  true  of  many  other 
forms  of  disease.  The  majority  of  the  insane  are  at  least 
equally  deserving  of  our  compassion  with  the  blind  or  the  lame. 
It  is  painful  enough  to  the  patient  to  be  deprived  of  the  mental 
faculties  enjoyed  by  the  average  man  ;  it  is  brutal  in  those  so 
fortunate  as  to  have  escaped  a  hke  calamity  to  aggravate  his 
suffering  by  want  of  Idndly  thought  and  charity.  It  is  the 
physician's  duty  to  guard  his  patient  from  the  thoughtlessness 
of  others,  to  inspire  for  him  a  feeling  of  sympath}^  and  to 
correct  the  disposition  of  the  ignorant  to  regard  him  as  beyond 
the  human  pale.  It  is  something  consistently  to  deprecate  and 
discourage  the  careless  use  of  obsolete  terms  such  as  *  mad  ' 
and  '  lunatic,'  expressions  which  convey  an  entirely  erroneous 
idea  to  the  average  mind  and  are  as  misleading  and  meaning- 
less as  terms  such  as  '  humours  '  and  '  distempers  '  would  be 
in  the  medical  diction  of  to-day. 

28 


434  iPSYCHOLOGICAL  MEDICIXE 

The  fii'st  aim  of  the  physician  should  be  to  encourage  early 
treatment,  for  there  are  many  forms  of  mental  disease  which 
in  then-  initial  stages  readily  yield  to  prudent  handling.  With 
these  prehminary  observations,  consideration  may  now  be 
directed  to  the  various  elements  which  go  to  form  what  is 
comprehensively  styled  'treatment.'  Much  nervous  and 
mental  disorder  can  be  prevented  by  teaching  the  value  of  a 
wise  and  careful  mode  of  life.  Preventive  medicine  should  be 
the  medicine  of  the  educated  classes  ;  and  it  is  one  of  the  duties 
of  the  physician  to  teach  his  patients  how  to  regulate  and  attend 
to  the  various  functions  of  the  body  and  to  understand  the 
working  and  the  welfare  of  then  mind. 

Preventive  Treatment. — The  preventive  treatment  of  mental 
disease  covers  a  very  large  field  of  study.  The  various  causes 
which  tend  to  produce  insanity  should  fii-st  be  reviewed,  and 
an  effort  then  made  to  remove  or  so  modify  them  as  to  render 
them  inert.  At  the  outset  of  such  a  task,  gigantic  in  itself, 
this  overwhelming  difficulty  presents  itself — that  that  which 
is  harmful  to  one  person  may  be  indifferent  in  its  effect  upon 
another  or  even  beneficial  to  him.  The  personal  equation 
or  individual  constitution  frec[uently  determines  the  effect  of 
stresses  upon  the  organism,  and  it  is  this  peculiar  idiosyncrasy 
that  is  so  difficult  to  gauge. 

It  is  not  possible  here  to  do  more  than  take  a  broad  review 
of  the  subject  with  special  reference  to  those  points  which 
seem  to  call  most  forcibly  for  consideration.  The  object  upon 
which  aspiration  should  fii'st  centre,  as  touching  the  most 
fruitful  som'ce  of  the  dissemination  of  mental  disease,  should 
be  the  prevention  of  propagation  of  insanity  from  generation 
to  generation.  This  question  is  largely  a  social  one  and  little 
can  be  done  until  pubhc  opinion  is  ripe  to  receive  dhection, 
which  is  equivalent  to  saying  until  the  problem  has  become 
so  serious  that  it  cannot  be  longer  overlooked.  Many  of  the 
insane  are  children  of  degenerate  parents,  and  consequently, 
if  the  mariiage  of  a  man  or  a  woman,  who  has  been  insane, 
epileptic  or  alcoholic,  were  made  penal,  or  the  contracting 
parties  in  some  way  made  amenable  to  law,  there  would 
doubtless  soon  be  a  very  appreciable  fall  in  the  number  of 
fresh  cases  of  mental  disease. 

The  liberty  of  the  subject  is  a  fundamental  doctrine  in  our 


TREATMENT  435 

national  creed.  This  liberty  of  the  individual  is,  however,  in 
any  state  of  society  subject  to  the  good  of  the  many.  The 
liberty  of  the  thief  to  steal,  or  the  murderer  to  slay,  has  long 
since  been  denied  him.  That  it  is  so  is  due  to  the  general 
appreciation  that  it  is  better  for  the  whole  body  that  indi- 
vidual liberty  in  such  respects  should  be  curtailed.  So  soon 
as  public  opinion  recognises  that  it  is  a  social  sin  for  the  unfit 
to  beget  or  bear  children,  who  in  turn  pass  on  the  taint  in 
ever-widening  progression,  legislative  interference  may  be 
expected. 

We  make  salutary  provisions  to  avoid  the  risk  of  infection 
of  physical  ills,  which  to  a  large  extent  are  of  a  merely  tem- 
porary nature  unaccompanied  by  permanent  injury.  To 
the  mental  side  of  disease,  infinitely  more  insidious  in  its 
effects,  infinitely  more  dangerous  to  descendants,  and  therefore 
infinitely  more  important  from  a  national  point  of  view,  no 
heed  is  given.  Something  is  being  done — very  little  and 
with  lamentably  little  profit — to  protect  the  degenerate  from 
his  own  weakness.  Nothing  is  being  done  to  protect  society 
from  the  degenerate. 

In  the  past  there  has  been  the  excuse  of  ignorance.  That 
plea  is  no  longer  permissible.  The  increase  of  scientific 
research  and  knowledge  has  made  the  facts  plain  for  all  who 
care  to  see. 

We  must  await  the  advent  of  a  statesman  whom  education 
and  inquiry  have  convinced  of  a  pressing  national  need,  and 
who  has  the  corn-age  to  undertake  an  unpopular  task.  The 
ojEfice  of  educating  pubhc  opinion  to  a  new  understanding  is 
never  popular.  The  majority,  unaffected  by  proposed  provi- 
sions, are  at  most  mildly  interested  in,  and  quite  apathetic 
about,  the  new  invasion.  The  minority,  whose  liberty  to  in- 
dulge its  personal  desires  at  the  national  expense  is  threatened, 
is  tumultuously  indignant.  The  reformer  loses  prestige  and 
is  defeated  ;  the  question  is  dropped  until  another  true  patriot 
steps  into  the  breach.  Ultimately  the  reform  comes,  but  not 
before  great  damage  has  been  done.  Meanwhile  voices  will  not 
be  lacking  indignantly  to  reiterate  the  invariable  objections. 
'  Where  will  it  end  ?  '  '  Where  are  we  to  draw  the  line  ?  '  The 
answer  is  simple  ;  the  most  timid  need  not  fear.  Before  any 
doubtful  ground  is  reached,  there  is  far  to  go.     Much  may 


436  PSYCHOLOGICAL  MEDICINE 

be  clone  without  passing   a  step  from  the  safe  platform  of 
indisputable  fact. 

We  have  before  us  the  example  of  countries  which  have 
slowly  deteriorated,  and  have  gradually  shpped  from  the  first 
to  the  second,  and  later  from  the  second  to  the  third  grade 
in  the  scale  of  nations,  largely  because  social  evils  have  flourished 
unmolested  until  degeneracy  has  gained  the  upper  hand. 
Such  has  been  the  fate  of  countries  in  the  days  of  darkness  ; 
but  are  we  to  sink  into  the  same  obscurity  for  the  hke  cause 
in  these  times  of  greater  enhghtenment  :  is  the  warning  of 
the  past  to  be  of  no  avail  ?  In  England  to-day  the  alcohoHc 
enjoys  the  same  privileges  as  the  hard-working  and  self- 
respecting  man  ;  and  yet  he  is  a  burden  to  the  State  in  his 
lifetime,  and  at  his  death  he  leaves  degenerate  offspring  as  a 
legacy  to  the  nation. 

In  earlier  chapters  the  claim  has  been  advanced  that  the 
morally  insane  and  other  degenerates  should  be  judged  more 
leniently  for  their  offences,  but  it  is  incumbent  upon  society 
to  protect  itself  from  the  consequences  of  their  ills.  Space 
wdll  not  permit  enlarging  further  on  this  important  subject, 
and  attention  must  now  be  directed  to  other  means  of 
preventing  the  development  of  mental  disease. 

In  the  chapter  on  the  causation  of  insanity,  emphasis  has 
been  laid  upon  the  importance  of  the  education  of  the  young 
on  rational  lines.  Similarly,  the  tendency  in  vogue  at  the 
present  time  to  force  the  mental  development  and  to  encourage 
the  brilliant  child  to  work  for  scholarship  examinations  has 
been  deprecated.  Parents  should  be  warned  not  to  allow 
themselves  to  be  flattered  by  teachers'  praise  of  the  intel- 
lectual abiUties  of  their  child,  whose  education  they  should 
jealously  watch  and  whose  future  they  should  guard  from 
the  danger  of  being  sacrificed  for  the  transient  kudos  of  early 
distinction. 

Children  should  be  trained  with  a  view  to  their  future 
work  in  life  ;  by  all  means  let  their  equipment  be  thorough, 
but  do  not  allow  their  mental  preparation  to  be  pressed  at 
the  expense  of  their  physical  development.  Slow  and  steady 
maturity  connotes  a  higher  degree  of  stabihty.  When  the 
period  of  puberty  is  reached  the  child  should  be  carefully 
watched,  and  school  work  should  be  somewhat  relaxed  until 


TREATMENT  437 

the  peculiar  stress  of  this  epoch  is  passed.  Physical  exercise 
should  be  carefully  regulated  ;  much  evil  may  result  from 
constant  or  excessive  bodily  fatigue. 

The  body  should  be  clothed  on  hygienic  lines  ;  the  tendency 
is  to  wear  too  much.  The  skin  requires  free  access  to  the 
air,  and  to  cover  it  with  materials  which  rapidly  become 
saturated  with  the  exudations  from  the  body  tends  to  produce 
disease.  Persons  who  feel  the  cold  will  often  heap  on  clothing, 
httle  realising  that  each  additional  article  conduces  to  defeat 
the  end  they  have  in  view.  Thick  underclothing  warms  the 
surface  and  brings  about  a  dilatation  of  the  capillaries  in  the 
skin  ;  the  blood  is  thereby  cooled,  and  the  sensation  of  cold  is 
not  lessened.  If  additional  clothing  is  required,  it  should  take 
the  form  of  outer  wraps,  which  can  readily  be  removed  when 
no  longer  required. 

Sitting  up  at  night  into  the  early  hours  of  the  morning  is 
one  of  the  most  certain  modes  of  producing  insomnia  and  is 
in  other  ways  injurious  to  health.  Diet  should  be  carefully 
regulated,  and  the  constant  eating  of  highly  seasoned  food 
stuffs  is  harmful  to  the  economy  of  the  organism.  Neurotic 
subjects  are  better  without  alcoholic  stimulants  ;  beverages 
such  as  milk  should  be  taken.  Work  should  be  confined 
to  proper  hours,  and  sufficient  time  should  be  allowed  for 
meals.  Many  a  man  has  sown  the  seeds  of  dyspepsia  and 
subsequent  ill  health,  not  uncommonly  leading  to  neur- 
asthenia or  mental  disorder,  by  taking  hasty  meals.  It  is  bad 
economy  to  monopolise  for  work  the  hours  which  should 
properly  be  used  for  eating  and  sleeping.  Periodically  there 
should  be  a  total  cessation  from  all  work  ;  the  annual  holiday 
should  be  looked  upon  as  a  necessity  rather  than  a  luxury. 
The  strenuous  life  must  have  constant  relaxation,  and  at 
least  one  hohday  in  each  year  should  be  of  a  prolonged  nature, 
All  this  and  a  great  deal  more  is  required  to  keep  a  sound 
mind  in  a  healthy  body. 

To  draw  nearer  to  the  subject,  if  an  individual  is  known 
to  be  predisposed  to  insanity,  his  education  and  training  call 
for  pecuhar  care  in  order  to  counteract  the  innate  tendency. 
The  difficulty  which  the  family  physician  has  to  surmount  is, 
that  inasmuch  as  the  instability  is  probably  a  heritage  from 
the  parent,  on  a  priori  grounds  the  parent  is  unsuited  to  train 


438  rSYCHOLOGIGAL  MEDICINE 

the  child.  Children  are  quick  to  imitate  their  teachers,  and 
irritabihty  and  discontent  may  be  readily  acquired  from  an 
eccentric  or  querulous  parent.  Degeneracy  in  the  heads  of  a 
household  permeates  the  whole  atmosphere  of  that  house,  and 
it  is  no  matter  for  surprise  that  the  receptive  mind  of  the 
child  becomes  affected.  Kindergartens  have  proved  them- 
selves to  be  invaluable  for  the  training  of  children  so  circum- 
stanced. The  kindergarten  not  only  removes  the  infant 
from  unhealthy  surroundings  and  teaches  control,  but  educates 
the  faculty  of  observation  and  manual  dexterity  without 
burdening  the  memory  with  facts. 

The  happiness  of  the  individual  depends  largely  upon 
how  he  was  taught  in  childhood  to  view  external  things. 
Peevishness  and  discontent  breed  jealousy  and  discord,  and 
these  in  their  turn  tend  to  suspicion  or  melancholy.  Selfish- 
ness begets  pride  and  inordinate  self-esteem,  and  these  may 
form  the  basis  of  subsequent  mental  disorder.  Instruct  the 
child  how  to  live  and  correct  vicious  tendencies,  teach  him 
that  he  is  born  into  a  community  in  which  the  good  of  others 
is  the  foundation  of  temporal  happiness.  As  soon  as  the 
lesson  of  altruism  is  learned,  the  groundwork  is  laid  for  other 
knowledge.  Kemember  that  information  can  always  be 
acquired  when  once  the  power  of  application  has  been  taught. 
It  is  otherwise  with  disposition.  Character  is  moulded  early 
in  life,  and  the  actions  and  thoughts  of  every  man  throughout 
his  Ufe  will  be  coloured  by  the  different  qualities  of  which  his 
character  consists. 

Before  passmg  on  to  consider  curative  measures,  a  short 
space  must  be  devoted  to  the  consideration  of  those  persons 
who  have  reached  adult  hfe  and  are  in  danger  of  a  mental 
breakdown.  The  term  '  incipient  insanity '  is  frequently 
applied  to  advanced  cases  of  mental  disease  ;  the  true  '  in- 
cipient '  stage  is  unhappily  too  often  overlooked.  In  some 
measure  the  fault  of  this  hes  with  the  medical  profession, 
the  members  of  which  do  not  devote  enough  attention  to 
studying  disease  in  its  very  earliest  phases.  There  is  too 
great  a  disposition  to  put  the  patient  off  with  some  common- 
place remark,  such  as  that  the  liver  is  out  of  order,  or  that  the 
system  requires  a  tonic.  Is  not  the  examination  of  a  patient, 
complaining   of    a    seemingly  trifling  disorder,  sometimes    a 


TREATMENT  439 

little  perfunctory,  a  little  lacking  in  thoroughness  ?  What- 
ever may  be  the  case  with  other  forms  of  disease — probably 
no  distinction  need  be  drawn — the  early  symptoms  of  mental 
disorder  are  very  insignificant ;  it  is  only  when  we  find  such 
symptoms  as  restlessness,  inattention,  and  irritabiUty  asso- 
ciated that  the  suspicion  arises  that  all  is  not  well.  Mental 
disorder  in  its  minor  forms  is  far  more  common  than  the  average 
practitioner  thinks  ;  probably  no  inconsiderable  percentage  of 
his  work  belongs  to  this  class. 

But  the  error  is  not  altogether  on  the  side  of  the  medical 
profession  :  it  is  in  the  ignorance  of  the  layman  that  the 
chief  danger  lies.  He  does  not  recognise  the  importance  of 
consulting  his  medical  attendant  when  change  of  character 
is  the  only  apparent  symptom.  He  attributes  to  bad  temper 
any  sudden  appearance  of  querulousness  or  irritability,  neglect- 
ing altogether  the  fact  that  the  sufferer  may  in  the  past  have 
been  of  a  disposition  uniformly  equable  and  placid.  It  is  only 
when  the  disease  becomes  established  that  the  friends  will 
tell  you  that  they  have  noticed  the  change  coming  on  for 
months,  but. that  they  '  thought  it  was  nothing.'  This  ignor- 
ance accounts  for  a  certain  proportion  of  the  insane  becoming 
confirmed  in  their  mental  disorder  ;  but  unhappily  the  folly 
bred  of  ignorance  does  not  end  here.  Even  when  relatives  or 
friends  have  had  their  suspicions  aroused  and  have  gone  so 
far  as  to  consult  a  physician,  they  will  resent  his  opinion  and 
ignore  his  advice  if  he  tells  them  the  truth.  It  is  wiser  to 
avoid  the  use  of  objectionable  terms  ;  even  so  colourless  an 
expression  as  '  incipient  insanity  '  is  not  the  best  way  of 
expressing  some  mental  change  due  to  nerve  exhaustion. 

The  physician  should  clearly  state  that  the  patient  must 
consent  to  be  treated,  and  should  definitely  indicate  the  risk 
which  neglect  of  this  advice  entails.  The  patient  should  be 
directed  to  give  up  all  work,  and  rest.  Travelling  is  bad  ;  as 
a  rule  the  patient  returns  worse  rather  than  better.  Physical 
exhaustion  increases  all  nervous  and  mental  symptoms. 
A  sea  voyage  or  foreign  travel  is  often  permitted  or  even 
suggested,  being  a  form  of  treatment  which  appeals  to  the 
patient,  as  he  is  restless  and  must  keep  on  the  move.  It 
is  nevertheless,  as  a  rule,  wrong  treatment.  Best  is  the  only 
way  by  which  the  nervous  system  can  recover  tone,  and  the 


440  PSYCHOLOGICAL  MEDICINE 

physician's  duty  is  to  place  the  patient  under  the  most  favour- 
able conditions  for  nature  to  do  its  work.  The  tendency  of  most 
diseases  is  towards  amendment,  but  this  tendency  is  not  proof 
against  conduct  calculated  to  aggravate  the  disorder.  To  be 
quiet  and  rest  is  the  most  difficult  of  all  advice  for  a  man  to 
follow,  but  he  is  a  poor  physician  whose  advice  must  accord 
with  his  patient's  wishes.  The  fact  that  a  patient  is  restless 
should  make  the  medical  attendant  all  the  more  determined 
in  his  actions  and  definite  in  his  instructions. 

Travelling  has  its  proper  place  in  the  scheme  of  treatment  of 
disease  ;  that  is  to  say,  it  comes  the  last.  It  should  be  the  final 
stage  before  returning  to  active  life,  and,  properly  employed, 
is  a  most  beneficial  remedy.  In  the  early  weeks  the  patient 
must  be  content  to  rest  quietly  in  some  farm  or  country  house 
and  be  fed  with  a  plentiful  supply  of  eggs  and  milk.  Watch 
the  body  weight  ;  it  usually  falls  before  the  development 
of  any  mental  disturbance  and  rises  when  the  patient  is  pro- 
gressing favourably.  The  appetite  frequently  becomes  enor- 
mous when  convalescence  sets  in  and  the  weight  may  increase 
rapidly.  This  should  give  rise  to  no  anxiety,  for  even  if  the 
patient  becomes  stout,  a  certain  amount  of  weight  will  dis- 
appear after  recovery.  It  is  a  well-recognised  fact  among 
physicians  experienced  in  mental  diseaSiO  that  so  long  as  a 
man  keeps  well  nourished  with  a  steady  weight  there  is  less 
likelihood  of  any  relapse. 

The  patient  should  live  by  rule  ;  his  day  should  be  carefully 
divided  so  as  to  permit  ample  opportunity  for  rest.  Exercise 
should  be  taken  sparingly  at  first,  but  as  strength  returns,  it 
may  be  increased.  A  cheerful  companion,  who  will  prevent 
time  hanging  too  heavily,  is  an  advantage.  The  hour  for 
retiring  at  night  should  not  be  later  than  ten  o'clock.  If  the 
patient  is  sleepless,  he  must  take  some  food  during  the  night 
and  if  necessary  be  given  a  sedative.  Attend  to  the  bowels 
carefully.  In  some  cases  a  course  of  mineral  waters  is  very 
beneficial.  Baths  may  be  occasionally  given  with  advantage. 
In  the  opening  chapters  we  referred  to  the  influence  of  habit 
on  the  individual.  Therefore  it  is  most  important  to  realise 
this  when  treating  nervous  disorders.  Wrong  ideas  may  have 
become  associated  together  and  these  must  be  disassociated 
if  possible.     Much  can  be  done  by  correcting  habits  of  thought 


TREATMENT  441 

and  action.  When  a  patient  is  improving  do  not  let  him  return 
to  work  too  soon  ;  it  is  a  common  mistake,  .and  frequently 
leads  to  a  serious  relapse. 

Curative  Treatment. — Attention  must  next  be  directed  to  the 
curative  measures  upon  which  reliance  should  be  placed  in  the 
treatment  of  mental  disorder  in  its  more  advanced  forms. 
When  such  marked  symptoms  of  mental  disturbance  have 
presented  themselves  that  relatives  begin  to  apprehend  the 
possibility  of  a  mental  breakdown,  it  is  usual  to  find  that 
insanity  is  so  well  established  that  a  prolonged  course  of 
treatment  will  be  necessary  before  health  can  be  restored.  In 
the  previous  chapter,  a  scheme  which  may  be  followed  by  the 
physician  in  making  an  examination  of  a  patient  who  shows 
symptoms  of  mental  disorder,  has  been  recommended.  Physi- 
cians whose  daily  duty  lies  in  the  care  and  management  of  the 
mentally  affected,  frequently  meet  with  a  scoffing  criticism, 
born  of  ignorance,  that  there  is  no  treatment  beyond  that  of 
attending  to  the  patient's  board  and  lodging  and  from  time  to 
time  relieving  urgent  or  distressing  symptoms.  Such  state- 
ments merely  prove  the  speaker  to  be  innocent  of  even  a 
superficial  knowledge  of  mental  disease.  He  demonstrates  his 
inability  either  to  diagnose  or  cope  with  mental  disorder  in  its 
earliest  forms.  What  a  formidable  list  of  diseases,  belonging 
either  to  the  province  of  medicine  or  surgery,  could  be  com- 
piled, in  "which,  if  through  neglect  during  the  earlier  months 
of  their  development  the  malady  has  become  organised,  palli- 
ative treatment  is  all  that  is  possible. 

Mental  disease,  like  many  other  maladies,  must  be  treated 
in  its  early  stages  if  complete  recovery  is  to  be  attained.  Who 
would  permit  a  case  of  phthisis  to  drift  until  the  lungs  had 
become  riddled  with  cavities  ?  But  if,  from  whatever  cause, 
such  was  the  plight  of  the  patient,  the  only  possible  treatment 
might  well  consist  in  attending  to  his  board  and  lodging 
and  from  time  to  time  relieving  urgent  or  distressing  symptoms. 
It  is  true  that  in  many  cases  of  insanity,  but  by  no  means  in 
all,  the  physician's  treatment  must  be  purely  palliative  ;  and  no 
one  deplores  it  more  than  he,  recognising  as  he  may  that 
the  hopelessness  of  the  condition  is  often  due  to  failure  on 
the  part  of  some  one  to  appreciate  sufficiently  early  the  onset 
of  disease. 


442  PSYCHOLOGICAL  MEDICINE 

The  first  duty  of  a  physician,  upon  seeing  his  patient,  is 
to  diagnose  the  condition.  Do  not  be  satisfied  merely  by 
finding  out  that  the  man  is  insane,  but  try  to  discover  whether 
there  is  a  physical  cause  that  has  given  rise  to  the  mental 
aberration.  If  some  bodily  disease  is  found,  its  relationship 
to  the  insanity  must  be  considered  ;  for  in  some  instances  the 
maladies  may  co- exist  ^dthout  marked  influence  upon  each 
other.  If  physical  disease  is  discovered,  it  must  be  treated, 
if  remedy  is  possible. 

The  next  point  to  be  decided  is,  where  shall  the  patient  be 
treated  ?  In  almost  every  case  it  is  necessary  to  remove  him 
from  his  home  sm-roundings.  There  are  many  com'ses  which 
may  be  taken,  the  financial  position  of  the  patient  being  as  a 
rule  the  determining  factor.  If  the  means  are  small,  alternatives 
are  correspondingly  few  ;  and  in  most  instances  the  patient 
must  be  sent  either  to  some  large  private  asylum  or  to  some 
hospital  for  mental  diseases  where  a  charge  of  about  thirty 
shillings  or  two  guineas  a  week  is  made. 

As  has  been  akeady  pointed  out,  there  is  a  very  considerable 
difference  between  '  unsoundness  of  mind  '  and  '  certifiable  in- 
sanity.' If  a  person  is  so  insane  as  to  be  certifiable,  then  he 
must  be  seen  by  two  medical  men  and,  upon  their  certificates 
and  a  reception  order  from  a  judicial  authority,  be  placed  in 
any  institution  where  private  patients  are  received.  Some 
persons  recognise  that  they  are  suffering  from  mental  disorder 
and  are  quite  wilHng  to  place  themselves  under  treatment.  If 
such  a  person  is  not  so  insane  that  he  ought  to  be  certified  and 
is  "^dUing  to  be  treated  in  a  hospital  or  private  asylum,  he  can 
do  so  by  signing  a  document  saying  that  he  wishes  to  place 
himself  under  the  care  of  the  medical  authorities  for  treatment. 
He  then  goes  into  the  institution  as  a  voluntary  boarder  ;  that 
is  to  say,  at  his  own  request.  The  patient  does  not  undertake 
to  stay  any  specified  time,  as  is  the  case  ^nth  alcoholics  under 
the  Inebriates  Act,  and  he  may  leave  at  any  time  upon  giving 
a  day's  notice  in  writing  to  the  medical  superintendent  ;  this 
notice  is  designed  to  give  time  for  communication  with  the 
man's  friends. 

If  the  patient  is  able  to  pay  about  three  or  four  guineas 
and  upwards  a  week,  his  friends  have  a  larger  choice  both 
of    hospitals    and    private    asylums.     The    advantages    that 


TREATMENT  443 

are  usually  to  be  derived  from  sending  a  patient  into  a  hos- 
pital for  mental  diseases  are  that  the  percentage  of  curable 
cases  is  generally  larger  than  is  found  in  private  institutions, 
and  there  is  commonly  greater  opportunity  for  amusement 
and  entertainment.  The  disadvantage  is  that  the  numbers 
are  so  much  greater  in  the  public  institutions  that  the  same 
amount  of  privacy  that  can  be  enjoyed  in  a  licensed  house 
is  not  obtainable.  The  main  advantage  of  a  private  asylum 
is  that  it  is  possible  to  obtain  a  greater  number  of  the  small 
comforts  of  hfe. 

The  pubhc  need  have  no  hesitation  in  placing  their  rela- 
tives in  these  private  homes,  as  in  the  vast  majority  of  them 
everything  possible  is  done  for  the  good  of  the  patients.  There 
is  no  need  to  fear  that  a  patient  will  be  detained  longer  than 
is  necessary,  nor  after  he  has  recovered.  Private  asylums 
have  the  same  official  supervision  from  the  Board  of  Control 
as  a  pubhc  hospital,  and  in  addition  six  visits  a  year  by 
the  visiting  justices  in  the  case  of  country  houses,  and  four 
extra  visits  annually  by  the  Board  of  Control  in  the  case 
of  houses  in  the  metropoHtan  district,  are  paid.  Further, 
save  in  very  exceptional  cases  in  which  the  patient  is  actively 
dangerous  to  himself  or  others,  the  petitioner  can  remove 
his  relative  at  any  time  ;  and  even  in  the  exceptional  instance 
just  cited  the  veto  which  the  medical  superintendent  can  exercise 
is  only  of  a  hmited  nature.  The  Act  endows  the  medical 
officer  with  the  power  of  objecting  to  the  removal  of  a  patient 
who  is  dangerous  to  himself  or  others,  unless  he  is  satisfied 
that  the  provision  that  is  being  made  for  him  is  adequate  ; 
and  if  he  exercises  this  right,  he  has  to  forward  his  objections 
in  writing  to  the  office  of  the  Board  of  Control.  Private 
asylums  are  most  valuable  institutions  for  the  treatment  of 
a  certain  class  of  the  insane  ;  and  even  if  they  were  the  legiti- 
mate objects  of  criticism  eighty  years  ago  (and  it  maybe  doubted 
whether  they  were  worse  managed  than  the  public  asylums 
of  those  times),  at  the  present  day  they  are  conducted  for 
the  good  of  their  patients. 

There  will  always  be  some  ignorant  persons  ready  to  retail 
exaggerated  and  sensational  stories  as  to  the  methods  em- 
ployed in  these  institutions  ;  they  need  not  be  taken  seriously, 
as  almost  invariably  it  proves  that  they  are  the  victims  of  a 


444  PSYCHOLOGICAL  MEDICINE 

vivid  imagination  or  varped  judgment.  Without  doubt 
some  private  asylums  are  good,  others  indifferent.  Are 
they  pecuHar  in  this  ?  May  not  the  hke  comment  be  made 
on  our  pubhc  institutions  with  equal  fairness  ?  The  system 
should  not  be  condemned  because  the  standard  is  not  equally 
high  in  all. 

When  money  is  not  an  object,  or  the  financial  position  is 
such  that  it  need  not  be  primarily  considered,  some  persons 
prefer  to  send  a  relative  to  the  private  house  of  a  medical 
man.  The  lunacy  law  permits  the  reception  of  one  certified 
patient  into  a  private  house,  and  a  second  may  be  sanctioned 
if  it  can  be  proved  to  the  satisfaction  of  the  Board  of  Control 
that  such  a  course  will  benefit  the  original  patient.  It  is  to 
be  hoped  that  the  day  is  not  far  distant  when  it  will  be  possible 
to  treat  persons  of  unsound  mind  for  a  limited  period  without 
having  to  certify  them  as  insane.  Many  of  the  public  object 
to  certificates  of  insanity,  as  they  consider  that,  even  after 
recovery,  the  fact  of  having  been  so  certified  leaves  a  stigma 
on  the  patient  which  may  interfere  with  his  future  work  in  life. 
It  is  for  this  reason  that  an  attempt  should  be  made  to  legalise 
the  detention  of  the  insane  for  a  term  of  six  months  if  necessary, 
dm-ing  the  early  stage  of  the  illness.  As  the  law  at  present 
stands,  anyone  who  takes  into  his  house  a  person  of  unsound 
mind,  who  is  certifiably  insane  and  yet  who  is  not  under 
certificates,  renders  himself  liable  to  prosecution  and  a  fine  of 
fifty  pounds.  There  is  no  doubt  that  the  existing  legal  require- 
ments are  objected  to  by  many  persons  ;  but  it  is  well  to 
remember  that  the  stringency  of  the  Lunacy  Act,  1890,  is  due 
to  the  attitude  of  the  public  at  the  time  when  its  provisions 
were  under  consideration.  The  public  demanded  greater  pro- 
tection for  the  insane,  and  they  got  it.  There  is  no  doubt 
that  in  certain  directions  the  stringency  of  the  Act  should  be 
relaxed,  but  taken  as  a  whole  it  has  proved  to  be  an  efficient 
and  workable  piece  of  legislation. 

Nevertheless  the  time  has  come  when  the  laiv  should  be 
altered  so  as  to  legalise  the  care  of  recent  and  acute  cases  in 
homes  or  institutions  without  necessitating  in  the  first  place 
the  patient's  being  certified  as  a  person  of  unsound  mind.  In 
the  spring  of  1915  the  Government  brought  in  a  Bill  with  this 
end  in  view  (the  Mental  Treatment  Bill).  In  this  Bill  a  period 
of  six  months  was  permitted  for  treatment  during  which  time 


=  TREATMENT  445 

all  that  was  required  was  a  statutory  notitication  to  the  Board 
of  Control.  This  system  has  been  working  in  Scotland  for 
over  fifty  years  and  there  is  not  a  single  case  on  record  in  which 
it  has  been  abused. 

After  the  Mental  Treatment  Bill  had  been  introduced  into 
the  House  of  Commons,  it  was  found  that  opposition  to  it 
would  be  raised,  and  as  at  that  time  no  controversial  measures 
were  being  taken,  the  Bill  was  withdrawn.  It  is  to  be  hoped 
that  when  the  War  is  over,  legislation  will  be  again  directed 
towards  correcting  a  serious  defect  in  the  existing  law. 

To  return  to  the  question  of  treatment  of  patients  in  single 
care.  This  is  a  very  favom'ite  mode  of  treatment  for  the 
more  wealthy  classes  ;  and  it  has  undoubted  merits,  not  un- 
accompanied by  definite  dangers.  Many  persons  take  mental 
patients  into  their  houses,  either  to  eke  out  a  slender  income 
or  to  enable  them  to  live  in  a  larger  house  than  would  be 
possible  but  for  the  presence  of  these  '  paying  guests.'  This 
is  all  quite  proper,  provided  that  in  undertaking  their  charge 
they  fully  realise  all  the  responsibilities  which  it  entails.  No 
person  should  undertake  the  care  of  an  acute  case  of  insanity 
unless  he  is  willing  and  able  to  devote  a  good  deal  of  his  time 
to  his  patient.  A  garden  is  usually  an  absolute  necessity,  for 
it  must  be  possible  for  a  patient  to  get  out  of  doors  without 
having  to  walk  on  the  public  roads.  Under  favourable  circum- 
stances there  is  no  arrangement  by  which  a  patient  can  have 
so  much  individual  attention  and  so  near  an  approximation 
to  home  comforts  as  in  single  care.  It  can  be  one  of  the 
best  or  one  of  the  worst  methods  of  treatment  of  the  insane, 
and  its  success  must  largely  depend  on  the  conscientious 
energy  of  those  who  undertake  it. 

A  brief  sketch  has  now  been  made  of  the  various  places 
in  which  a  patient  can  be  treated.  They  all  have  their  ad- 
vantages and  disadvantages  ;  the  choice  in  any  given  case 
must  vary  with  the  requirements  and  financial  position  of 
the  patient.  In  coming  to  a  decision,  the  type  of  the  mental 
disorder  from  which  the  individual  is  suffering  must  also  be 
considered.  For  instance,  a  violent  case  of  acute  mania  cannot 
readily  be  treated  in  a  private  house,  and  very  suicidal  persons 
also  require  special  arrangements. 

Wherever  a  patient  is  sent,  the  treatment  must  be  the  same, 
and  this  is  the  next  topic  for  detailed  discussion.     The  first  and 


446  PSYCHOLOGICAL  MEDICINE 

all-important  point  is  to  secure  rest  for  the  patient.  It  is 
most  extraordinary  to  find  that  the  value  of  rest  in  the  treat- 
ment of  the  insane  is  so  little  appreciated  and  understood. 
Absolute  rest  in  bed  is  undoubtedly  the  best,  and  it  may  almost 
be  said  the  only,  way  in  which  acute  cases  may  be  treated. 
The  term  acute  is  used  as  indicative  of  recent  and  early  cases. 
Eest  is  freely  used  in  other  branches  of  medicine  and  surgery 
and  yet  is  often  denied  to  the  sufferer  from  mental  disorders 
whose  condition  above  all  others  claims  it.  People  who  are 
weary  both  in  mind  and  body  are  often  tramped  about  by 
nurses  instead  of  being  encouraged  to  stay  in  bed.  It  is  of 
com'se  very  hard  to  keep  some  patients  in  bed,  but  the 
difficulty  should  be  faced  and  not  shirked.  Eest  breeds  a 
desire  for  rest  ;  a  habit  of  rest  may  be  established,  and  a 
disposition  to  restlessness  overcome. 

The  emphasis  here  laid  upon  the  importance  of  rest  must 
not  be  misconstrued  into  a  suggestion  that  it  is  always  ap- 
propriate and  will  always  prove  beneficial.  It  must  not  be 
supposed  that  merely  because  a  person  is  insane  he  should  be 
kept  in  bed.  For  instance,  in  most  cases  of  chronic  mental 
disease  it  would  be  useless.  But  with  persons  who  suffer 
from  recurrent  outbreaks  of  excitement  or  depression,  the 
judicious  employment  of  occasional  days  in  bed  may  ward  off 
the  attacks.  Again,  rest  in  bed  is  not  of  much  value  in  the 
case  of  patients  with  chronic  delusional  insanity,  or  in  cases 
in  which  the  mental  aberration  has  been  progressing  over 
an  extended  period  of  time.  Its  greatest  utiUty  will  be  found 
in  the  treatment  of  recent  cases  of  mania  and  melancholia. 
These  patients  should  be  kept  absolutely  in  bed  for  some 
weeks.  The  rooms  in  which  they  are  kept  should  be  airy 
and  well  ventilated.  During  the  spring  and  summer  months 
much  advantage  might  be  gained  by  placing  some  of  the 
patients  on  beds  in  the  open  air  during  the  day.  Eooms 
might  be  specially  built  in  which  the  roofing  would  be  the 
only  fixed  part,  the  sides  and  ends  being  thrown  open  in 
suitable  weather.  After  a  patient  has  sufficiently  improved, 
he  may  be  allowed  to  get  up  once  or  twice  a  day  to  take  a 
little  exercise,  but  he  should  return  to  bed  when  this  is  over. 
In  this  way  a  patient  can  be  kept  completely  at  rest  for  many 
weeks  until  his  strength  has  returned  and  with  it  a  marked 
mental  improvement.    Massage  is  not   of  great   use  in  the 


TREATMENT  447 

treatment  of  the  insane,  and  though  valuable  in  some  cases,  in 
the  majority  it  is  not  to  be  recommended  ;  reliance  will  be 
more  wisely  placed  upon  rest  and  good  feeding. 

Diet. — The  diet  should  consist  of  a  liberal  supply  of 
nourishing  food.  Milk  is  invaluable  in  the  treatment  of 
mental  disease,  and  patients  should  take  at  least  a  pint  and 
a  half  a  day  in  addition  to  their  regular  food.  When  possible 
the  addition  of  some  cream  to  the  milk  is  helpful  in  fattening 
the  patient.  New-laid  eggs  are  also  an  excellent  food  for 
the  mentally  afflicted.  Milk  puddings  and  other  farinaceous 
food  stuffs  should  be  added  to  the  dietary.  Fish  and  meat 
may  be  given  with  advantage,  but  the  amount  of  meat  should 
be  Hmited.  The  latter  should  be  hghtly  cooked.  Fresh  vege- 
tables are  important,  and  should  be  given  daily. 

During  the  early  weeks  of  illness  it  will  be  necessary  to 
keep  a  close  watch  on  the  amount  of  food  the  patient  takes, 
and  if  enough  is  not  taken  at  each  meal,  he  must  be  fed  with  a 
basin  of  bread  and  milk,  or  persuaded  to  drink  a  tumbler  oi 
milk  in  which  an  egg  has  been  beaten  up.  A  conscientious 
nurse,  who  will  never  allow  the  patient  to  pass  a  meal  without 
seeing  that  he  has  eaten  a  sufficient  quantity  of  food,  is  most 
helpful  in  treating  acute  cases.  As  convalescence  sets  in,  the 
tendency  is  for  a  patient  to  eat  enormous  quantities  of  food, 
and  this  should  be  permitted  so  long  as  the  food  is  assimilated 
and  there  is  no  sickness.  Dements  will  usually  eat  more  than 
is  good  for  them,  and  their  appetite  must  be  watched  and  the 
amount  of  food  regulated.  Dietary  in  its  application  to  special 
diseases  has  been  touched  upon  in  describing  the  various  forms 
of  insanity. 

Alcohol. — Alcohol  is  not  required  and  need  not  be  given. 
To  many  patients  it  is  harmful ;  milk  or  Hme  juice  should  be 
substituted.  On  the  other  hand,  in  certain  cases  already 
indicated,  it  is  most  necessary  to  give  alcohol,  as  without  its 
assistance  such  patients  would  die.  In  the  nerve  exhaustion 
cases  stout  will  often  be  helpful. 

Forcible  Feeding. — The  various  means  of  artificial  feeding  at 
our  disposal  are  :  (a)  feeding  cup,  (&)  spoon  feeding,  (c)  nasal 
tube,  (d)  large  oesophageal  tube,  (e)  rectal  feeding. 

Feeding  by  means  of  a  feeding  cup  or  spoon  is  a  useful 
mode  of  giving  nourishment  in  a  certain  class  of  the  insane, 
but  the  use  of  these  aids  is  necessarily  limited  to  those  cases 


448  PSYCHOLOGICAL  MEDICINE 

in  which  there  is  no  very  active  resistance.  For  obvious 
reasons  rectal  feeding  is  of  little  value  in  the  treatment  of 
mental  disease,  except  in  those  cases  in  which  stomach  feeding 
is  contra-indicated  and  in  which  there  is  no  resistance.  The 
insane  require  a  large  amount  of  food,  and  this  can  only  be 
given  when  the  food  is  passed  into  the  stomach.  Some  autho- 
rities favour  nasal  while  others  prefer  oesophageal  feeding. 
Probably  neither  is  suited  to  all  patients,  each  having  both 
advantages  and  disadvantages.  It  is  by  experience  that  the 
physician  must  determine  which  method  to  adopt  in  any  given 
case. 

These  feedings  are  performed  in  the  following  way  :  The 
patient  is  either  held  in  a  chair  or  laid  on  a  mattress,  the 
latter  being  usually  the  preferable  course.  His  head  is  placed 
upon  a  firm  pillow,  and  a  nurse  kneels  and  holds  the 
patient's  head  between  his  hands,  or,  if  necessary,  between 
his  knees,  care  being  taken  not  to  injure  or  bruise  the  ears. 
If  assistance  is  difficult  to  get,  a  second  nurse  can  kneel 
on  a  towel  or  sheet  which  has  been  stretched  across  or  above 
the  patient's  knees,  and  the  same  nurse  can  hold  both 
the  patient's  wrists.  If  there  are  plenty  of  nurses  available 
or  the  patient  is  incUned  to  struggle  violently,  it  is  wise 
to  have  an  assistant  for  each  leg  and  arm.  On  no  account 
must  anyone  be  allowed  to  kneel  directly  on  any  limb  of 
the  patient. 

Nasal  Feeding. — This  is  carried  out  by  passing  a  long  soft 
red  rubber  tube  (size  No.  11-12),  to  which  a  funnel  has  been 
attached,  through  the  nose  into' the  oesophagus.  The  tube 
must  be  carefully  lubricated  with  oil.  Usually  it  will  be  found 
that  one  side  of  the  nose  allows  a  passage  more  readily  than 
the  other,  owing  to  some  deflection  of  the  nasal  septum.  When 
the  tube  has  been  passed,  a  httle  of  the  fluid  can  be  poured 
into  the  fmmol  in  order  to  see  whether  the  tube  is  clear.  The 
advantages  of  nasal  feeding  are  as  follows  :  (a)  that  fewer  nurses 
are  needed  to  hold  the  patient ;  (b)  that  no  gag  is  required, 
and  therefore  there  is  no  risk  of  damage  to  the  teeth ;  (c)  that 
regurgitation  or  vomiting  is  more  difficult  to  effect  and  is  less 
liable  to  occur  when  the  tube  is  withdrawn.  The  disadvantages 
are  not  of  a  serious  kind,  viz.  :  (a)  that  nasal  takes  a  longer 
time  than  oesophageal  feeding  ;  (&)  that  the  lumen  of  the  tube 
being  smaller,  it  is  more  readily  blocked  up  by  mucus  or  sohd 


TREATMENT  449 

masses  of  food  ;  (c)  that  if  a  patient  is  continually  shouting 
while  the  phj^sician  is  passing  the  tube,  it  readily  goes  into 
the  month  or  larynx  ;  this  is  at  once  recognised  by  the  stridor 
which  it  sets  up  ;  [d)  that  nasal  feeding,  if  long  continued, 
may  lead,  though  rareh^  to  a  troublesome  form  of  ulceration 
of  the  mucous  membrane  of  the  nose. 

OEsojjhageal  Feeding. — The  tube  used  in  oesophageal  feeding 
is  a  soft  red  rubber  tube  (No.  24-28).  With  this  method  a 
gag  is  required  unless  a  patient  has  lost  all  his  teeth.  The 
serrated  surface  of  the  gag  must  be  protected  with  some  rubber. 
If  there  is  any  difficulty  in  inserting  the  gag,  the  handle  of 
a  spoon  will  be  found  useful  in  separating  the  teeth.  Care 
must  be  exercised  not  to  try  to  force  the  patient's  mouth  open 
too  rapidly,  otherwise  the  jaw  may  be  fractured.  The  mouth 
does  not  require  to  be  opened  very  wide.  The  tube  can  be 
lubricated  by  dipping  it  into  the  food,  as  this  is  preferable  to 
using  oil.  The  tube  is  passed  to  the  back  of  the  pharynx, 
and  when  the  patient  swallows,  it  is  carried  down  into  the 
cesophagus.  Do  not  pass  the  tube  into  the  stomach,  as  it  is 
not  only  unnecessary  but  increases  the  liabihty  to  vomiting. 

The  following  are  the  advantages  of  this  mode  of  feeding  : 
[a)  that  the  meal  can  be  more  rapidly  given  ;  {b)  that  more 
sohd  food  can  be  administered,  and  drugs  such  as  sulphonal 
will  pass  through  the  tube  without  causing  a  blockage.  The 
disadvantages  are  :  (a)  that  a  greater  number  of  assistants 
is  usually  required  than  with  nasal  feeding  ;  (6)  that  a  gag 
has  to  be  employed  ;  (c)  that  regurgitation  of  food  can  easily 
l:e  effected  by  many  patients.  If  food  is  vomited  into  the 
mouth  hy  the  side  of  the  tube,  the  tube  and  the  gag  must  at 
once  be  withdrawn  to  allow  the  patient  to  empty  his  mouth, 
otherwise  food  will  be  drawn  into  the  air-passages  ;  (d)  that 
persons  with  a  smaU  pharynx  become  very  cyanosed  during 
the  feeding  ;  (e)  that  when  the  tube  is  withdrawn  at  the  com- 
pletion of  the  feeding,  there  is  greater  liability  to  vomiting  than 
is  the  case  when  a  nasal  tube  is  withdrawn.  To  obviate  this 
difficulty  we  recommend  that  the  operator  remove  the  tube 
during  inspiration. 

The  food  that  is  given  in  either  nasal  or  a3Sophageal  feed- 
ing should  consist  of  milk  (at  least  three  pints  daily),  eggs 
(four  to  six  daily),  soups,  vegetable  extracts,  stimulants,  and 
salt.     Peptonised  foods  are  often  useful.     The  quantity  given 

29 


450  PSYCHOLOGICAL  MEDICINE 

at  each  meal  should  be  rather  more  than  a  pint,  the  allowance 
for  men  being  somewhat  larger  than  that  for  women.  If 
there  is  a  tendency  to  vomiting,  it  is  advisable  to  concentrate 
the  meal  into  a  smaller  quantity.  Patients  must  be  fed  three 
or  four  times  a  day,  and  if  seriously  iU  or  in  a  very  weak  state, 
they  may  be  fed  every  fom-  hours  night  and  day.  The 
addition  of  some  cream  to  the  meal  is  useful  in  some  cases. 

Bowels. — The  bowels  require  constant  attention.  As  has 
been  pointed  out,  constipation  is  a  very  common  symptom  in 
all  forms  of  mental  disorder,  and  there  is  little  doubt  that 
chronic  constipation  is  an  important  factor  in  the  production 
of  insanity.  Fm'ther,  the  fact  that  auto-intoxication  is  now 
considered  to  be  a  weighty  element  in  mental  disease  accen- 
tuates the  necessity  of  keeping  the  bowels  freely  open.  Many 
persons  do  not  take  a  sufficient  amount  of  water  to  drink  and 
this  should  be  corrected.  The  regular  habit  of  obtaining  a 
daily  action  of  the  bowels  should  be  formed.  In  other  cases 
the  bowels  act  too  freely  and  require  regulating. 

T\Tien  aperient  treatment  is  necessary,  the  employment  of 
mineral  waters  may  be  invaluable.  Salts  have  the  great 
advantage  over  other  varieties  of  purgatives  in  that  the  more 
they  are  used  the  more  intolerant  the  patient  becomes 
towards  them  ;  in  other  words,  the  dose  has  to  be  steadily 
lessened  after  they  have  been  taken  for  some  time.  With 
most  purgatives  the  effect  is  exactly  the  reverse  and  the 
dose  has  to  be  constantly  increased  in  order  to  obtain  the  desired 
result.  Of  the  aperients  most  commonly  used  cascara  sagrada, 
either  in  the  form  of  tabloids  or  Hquid  extract,  is  useful. 
Calomel  has  the  advantage,  very  considerable  in  some  cases, 
that  it  can  be  so  easily  administered.  Soap  or  oil  etiemata 
are  preferable  to  aperients  in  the  treatment  of  some  patients 
and  may  be  giverl  three  or  four  times  a  week,  or  a  warm  water 
enema  may  be  administered  daily. 

If  the  patient  is  very  insane,  the  nurse  should  keep  a  careful 
record  of  the  action  of  the  bowels,  as  through  neglect  serious 
obstruction  may  occur.  Some  hypochondriacal  persons  are 
constantly  complaining  that  their  bowels  never  act  and  they 
will  ask  daily  for  aperients  which  are  not  only  unnecessary 
but  actually  harmful.  It  is  well  from  time  to  time  to  keep 
such  persons  in  bed  and  make  them  use  a  night  stool,  so  that 
the  action  can  be  inspected.     In  conclusion,  the  student  must 


TREATMENT  451 

remember  that  careful  attention  to  the  bowels  is  one  of  the 
most  necessary  details  in  the  treatment  of  the  insane,  as  a 
loaded  condition  of  the  intestines  will  aggravate  all  the  mental 
symptoms. 

Treatment  of  Intestinal  Infection. — Apart  fiom  the  treat- 
ment of  constipation  by  aperients,  many  authorities  advocate 
the  use  of  intestinal  disinfectants.  There  is  no  doubt  that 
many  of  the  insane  are  affected  by  the  continual  absorption 
mto  the  blood  of  poisonous  substances  which  are  generated 
by  putrefactive  and  fermentative  changes  taking  place  in  the 
intestines.  Some  physicians  advise  five-grain  doses  of  beta- 
naphthol  to  be  taken  about  two  hours  after  food  ;  others  prefer 
sodium  salicylate  or  salol.  If  the  patient  is  being  tube-fed, 
the  mouth  must  be  constantly  swabbed  out  with  a  plug  of 
lint  satm-ated  with  boric  glycerine. 

Exercise. — Great  stress  has  akeady  been  laid  on  the  im- 
portance of  ordering  as  much  rest  as  possible  in  the  treat- 
ment of  mental  disorder.  As  the  strength  improves,  gentle 
exercise  can  be  permitted  ;  the  patient  should  never  be  allowed 
to  become  fatigued.  The  antiquated  theory  that  the  restless 
patient  should  be  thed  out  by  exercise  is  erroneous.  At 
first  exercise  should  be  limited  to  one  or  two  hours  a  day. 
Even  when  convalescence  is  well  established,  great  care  should 
be  taken  to  prevent  the  patient  from  overdoing  himself.  On 
the  other  hand,  if  the  physical  strength  is  good  and  there 
are  no  signs  of  exhaustion,  physical  exercise  may  be  pre- 
scribed with  advantage  and  may  take  the  form  of  games 
such  as  golf  or  tennis.  Physical  drill  is  very  beneficial  to  the 
adolescent  cases  of  mental  disorder,  and  whenever  possible 
should  be  conducted  daily  for  a  short  time. 

Relaxation  Exercises.  —  In  some  forms  of  mental  dis- 
turbance and  more  especially  m  fatigue  states  relaxation 
exercises  will  be  found  a  most  valuable  adjunct  to  other  methods 
of  treatment.  Patients  will  often  complain  that  thoughts 
race  through  then'  minds.  Now  we  have  very  little  power 
over  our  thoughts  when  we  can  no  longer  work  owing  to  fatigue. 
It  is  useless  to  tell  the  patient  to  ignore  his  thoughts,  to  interest 
himself  in  other  things,  and  to  think  of  other  things,  for  the 
mv-^chanism  w^hereby  he  can  do  this  is  for  the  moment  dis- 
ordered. Now  we  know  that  active  attention  states  requiie 
tension  of  the  muscular  system  and  that  the  more  closely  we 


•452  PSYCHOLOGICAL  MEDICINE 

attend  the  greater  is  this  rigidity.  On  the  other  hand  we  know 
that  in  repose  and  sleep  the  muscles  are  flaccid.  Therefore  the 
more  flaccid  our  muscles  are,  the  more  reposeful  we  ought  to 
be,  and  this  is  true.  The  reader  should  try  it  for  himself  in 
fatigue  states  when  everything  seems  a  strain.  The  best  way 
to  relax  the  muscles  is  to  lie  down,  with  all  garments  loose  and 
the  eyes  closed  or  blindfolded,  and  then  think  of  relaxing  limb 
by  hmb  until  the  muscles  become  so  flaccid  that  when  raised 
by  another  person  they  fall  Hmp  and  lifeless  on  to  the  couch. 
The  neck  muscles  can  be  relaxed  in  the  same  way.  To  relax 
the  muscles  of  the  trunk  the  patient  is  instructed  to  think 
that  his  body  is  expanding  from  side  to  side.  If  when  weary 
one  hes  down  and  closes  one's  eyes  and  thinks  of  the  width 
of  the  body,  it  will  feel  narrow  ;  then  as  one  thinks  of  expand- 
ing, the  sense  of  narro^vness  disappears.  It  requires  constant 
practice  to  learn  to  relax  muscles  and  patients  should  be  in- 
structed in  these  exercises  day  by  day  until  acquired.  Further, 
on  recovery  the  power  of  being  able  to  relax  muscles  is  a  useful 
ajsset  in  the  prevention  of  relapses  or  subsequent  attacks  of 
nervous  disturbance,  especially  those  of  the  fatigue  type. 

Breathing  Exercises.  —  Many  persons  do  not  use  their 
thoracic  or  abdominal  muscles  properly  during  respiration. 
Bad  tricks  or  habits  of  breathing  may  have  been  acquired. 
Kespiration  may  be  too  shallow  and  in  turn  lead  to  defective 
oxygenation  of  the  blood.  Thoracic  and  abdominal  breathing 
should  be  taught  and  active  and  passive  breathing  exercises 
should  be  given  by  the  nurse.  These  exercises  often  greatly 
assist  in  the  recovery  of  the  patient. 

Sleep. — The  important  question  of  sleep  has  been  fully 
dealt  with  elsewhere. 

Violence. — Some  patients  are  so  intensely  violent  that  this 
symptom  requires  special  treatment.  In  a  private  house 
violence  is  very  difficult  to  control  and  has  usually  to  be 
restrained  either  by  drugs  or  mechanical  means.  Neither  of 
these  methods  can  be  considered  satisfactory,  and  for  this 
leason  violent  patients  should  be  treated  in  hospitals  or 
asylums,  Manj''  patients  who  constantly  struggle  and  fight 
with  nurses,  will,  when  left  alone,  become  tranquil.  Tem- 
porary seclusion  is  one  of  the  best  ways  of  treating  violence. 
The  term  '  seclusion  '  signifies  the  isolation  of  a  patient  in  a 


TREATMENT  453 

room  by  himself.  This  can  be  done  in  a  small  bedroom,  the 
windows  of  which  are  protected  and  in  which  there  is  no  break- 
able fmiiitm-e.  In  some  institutions  padded  rooms  are  used 
for  this  purpose.  A  padded  room  is  a  chamber  in  which  the 
walls  and  floor  are  protected  b}^  cushions  of  shredded  cork 
or  other  substances  covered  by  rubber  or  canvas.  These 
rooms  are  very  valuable  .for  infirm  patients  who  are  restless 
and  apt  to  fall  about.  If  a  patient  is  alone  he  must  be  con- 
stantty  visited  or  observed  through  a  window  in  the  door. 
Some  authorities  give  hypodermic  injections  of  hyoscin, 
hyoscyamin,  or  duboisin,  or  large  doses  of  hypnotic  drugs  to 
excited  patients,  but  probably  seclusion  is  preferable.  In 
institutions  for  the  insane  the  amount  of  seclusion  and  the 
reason  for  its  employment  have  to  be  entered  each  day  in 
a  special  journal  kept  for  the  purpose. 

More  rarely  patients  are  met  with  who  are  so  violent  that 
they  are  not  fit  to  be  left  in  seclusion,  as  they  may  seriously 
injure  themselves.  The  treatment  of  such  cases  is  very 
difficult  and  much  responsibihty  is  involved  in  the  care  of 
them.  Three  courses  are  open  ;  the  patient  may  be  stupefied 
with  some  drug  in  the  hope  of  inducing  sleep  ;  he  may  be  held 
hj  several  nurses  ;  or  he  may  be  restrained  by  mechanical 
means.  Probably  in  these  exceptional  cases  the  last-named 
method  is  the  best,  and  the  second  is  perhaps  the  most  ob- 
jectionable. Constant  struggling  with  a  patient  hour  after 
hour  must  be  bad  and  is  very  trjdng  to  the  temper  of  the 
best  nurse.  The  use  of  mechanical  restraint  ought  not  to  be 
encouraged  and  resort  should  not  be  had  to  it  unless  it  be 
absolutely  necessary  for  the  protection  of  the  patient  or  others. 
The  tendency  of  the  present  time  is  for  mechanical  restraint  to 
disappear  as  a  mode  of  treatment ;  nevertheless  in  some  cases  it 
may  be  employed  ^nth  advantage.  For  example,  a  very  suicidal 
patient  can  frequentl}'  be  kept  quiet,  and  may  even  fall  off  to 
sleep,  when  restrained  mechanically.  Also  patients  wdio  are 
constantly  trying  to  injure  their  eyes  or  other  parts  of  the 
bod}'  should  be  restrained  by  using  special  gloves. 

There  is  a  tendency  in  some  quarters  to  employ  chemical 
rather  than  mechanical  restraint.  The  use  of  drugs  for  allay- 
ing excitement  is  very  valuable  in  some  cases,  but  should  be 
avoided  where  possible  in  acute  recent  cases. 


454  PSYCHOLOGICAL  MEDICINE 

That  mechanical  restraint  should  be  used  very  sparingly 
and  only  when  the  patient's  condition  requires  it  cannot  be 
too  strongly  urged  ;  undeniably,  however,  it  has  a  place  in 
the  treatment  of  the  insane  and  is  preferable  to  drugs  in 
curable  cases.  The  best  and  most  common  form  of  restraint 
is  padded  gloves.  Perhaps  the  term  '  mechanical  restraint '  is 
too  forcible  for  so  sHght  an  interference  with  the  movements  of 
the  patient  and  might  with  advantage  be  reserved  for  the  more 
severe  forms,  which  are  seldom  employed.  Padded  gloves 
have  the  objection  that  the  lock  vdth.  wliich  they  are  fastened 
is  apt  to  cause  an  abrasion  of  the  skin  of  the  wrist.  This  evil 
could  be  avoided  by  mak'ng  the  glove  and  sleeve  in  one  piece  ; 
in  other  words,  the  sleeve  might  end  blhidl}''.  For  some  reason 
the  Board  of  Control  have  omitted  this  from  their  hst  of 
legal  methods  of  restraint,  and  consequently  it  cannot  be 
aiiployed  at  the  present  time.  Only  certain  forms  of  re- 
straint may  legally  be  used,  according  to  the  rules  of  the 
Board  of  Control.  The  proper  miderstanding  of  what  is 
lawful  restraint  is  so  important  that  the  student  will  do 
well  to  read  careful!}^  the  following  regulations,  which  are 
those  drawn  up  by  the  Board  pursuant  to  section  40  of  the 
Lunacy  Act,  1890  : 


[Copy] 

'Begulation  made  hy  the  Board  of  Control  as  to  Instru- 
ments and  Ajypliances  for  the  Mechanical  Restraint  of 
Lunatics 

'  Lunacy  Act,  1890,  Section  40 

'  (1.)  ]\lechanical  means  of  bodilj^  restraint  shall  not  be 
applied  to  any  lunatic  unless  the  restraint  is  necessary  for 
purposes  of  surgical  or  medical  treatment,  or  to  prevent  the 
lunatic  from  injuring  himself  or  others. 

'  (2.)  In  every  case  where  such  restraint  is  applied  a  medical 
certificate  shall,  as  soon  as  it  can  be  obtained,  be  signed, 
describing  the  mechanical  means  used,  and  stating  the  grounds 
upon  which  the  certificate  is  founded. 

'  (3.)  The  certificate  shall  be  signed,  in  the  case  of  a  lunatic 
in  an  institution  for  lunatics  or  workhouse,  by  the  medical 


TREATMENT  455 

officer  thereof,  and  in  the  case  of  a  single  patient,  by  his  medical 
attendant. 

'  (4.)  A  full  record  of  every  case  of  restraint  by  mechanical 
means  shall  be  kept  from  day  to  day  ;  and  a  copy  of  the 
records  and  certificates  under  this  section  shall  be  sent  to  the 
Commissioners  at  the  end  of  every  quarter. 

'  (5.)  In  the  case  of  a  workhouse,  the  record  ,to  be  kept 
under  this  section  shall  be  kept  by  the  medical  officer  of  the 
workhouse,  and  the  copies  of  records  and  certificates  to  be  sent 
shall  be  sent  by  the  clerk  to  the  guardians. 

'  (6.)  In  the  application  of  this  section  "  mechanical  means  " 
shall  be  such  instruments  and  appliances  as  the  Commissioners 
may,  by  regulations  to  be  made  from  time  to  time,  determine. 

'  (7.)  Any  person  who  wilfully  acts  in  contravention  of  this 
section  shall  be  guilty  of  a  misdemeanour. 


'  Begulation 

'  In  pursuance  of  sub-section  six  of  the  above  section  of  the 
Lunacy  Act  1890,  the  Board  of  Control,  by  this  regulation 
under  their  common  seal,  do  hereby  determine  that 
"  mechanical  means  of  bodily  restraint  "  shall  include  all 
instruments  and  appliances  whereby  the  free  movement  of 
the  body  or  of  any  of  the  hmbs  of  a  lunatic  are  restrained  or 
impeded,  but  that  the  following  instruments  and  appliances 
only  shall  be  made  use  of  for  such  purpose  : 

'  1.  A  jacket  or  dress,  laced  or  buttoned  down  the  back, 
made  of  strong  linen,  with  long  outside  sleeves  fastened 
to  the  dress  only  at  the  shoulders,  and  having  closed 
ends  to  which  tapes  may  be  attached  for  tying  behind 
the  back  when  the  arms  have  been  folded  across  the 
chest. 

'  2.  Gloves  without  ffiigers,  fastened  at  the  wrists  with 
buttons  or  locks,  and  made  of  strong  hnen  or  chamois 
leather,  padded  or  otherwise. 

*  3.  If  the  continuous  bath  be  employed,  the  use  of  a  cover 
to  the  open  bath,  with  an  aperture  therein  for  the 
patient's  head,  shall  be  deemed  to  be  mechanical  means 
of  restraint. 

'  4.  The  wet  or  dry  pack. — If,  and  when,  either  is  used,  the 
patient  shall  be  swathed  in  sheets  and  blankets  only, 
the  outer  sheet   being,  if  necessary,   sewn  or  pinned. 


456  PSYCHOLOGICAL  MEDICINE 

No   straps  or  ligatures  of  any  kind  shall  be  used,  and 
the   patient   shall  be  released  for  necessary  purposes 
at  intervals  not  exceeding  two  hours. 
'  5.  Sheets  or  towels  when  tied  or  fastened  to  the  sides  of 
a  bed  or  other  object. — When  these  are  used  only  for 
the  purpose  of  forcible  feeding,  and  merely  held  by 
attendants,  and  not  tied  or  fastened,  their  use  shall  not 
be  considered  to  come  under  the  head  of  mechanical 
restraint. 
'  It  is  essential  to  the  safe  employment  of  any  of  these 
forms  of  restraint,  except  No.  2,  that  the  patient  be  visited 
frequently  by  a  medical  officer,  that  he  be  kept  under  con- 
tinuous special  supervision  by  an  attendant,  and  that  under 
no  circumstances  he  be  left  unattended  ;    and  it  is  hereby. so 
ordered. 

'  The  Commissioners  direct  that  at  each  visit  of  Commis- 
sioners or  a  Commissioner  to  an  asylum,  hospital,  or  Hcensed 
house,  or  to  a  single  patient,  all  instruments  and  mechanical 
appliances  which  may  have  been  employed  in  the  application 
of  bodily  restraint  to  a  lunatic  since  the  last  preceding  visit, 
be  produced  to  the  Visiting  Commissioners  or  Commissioner 
by  the  superintendent,  resident  medical  officer,  or  resident 
licensee,  or  the  person  having  charge  of  the  single  patient. 

'  It  will  be  seen  that  the  section  requires  that  in  every  case 
where  mechanical  restraint  is  applied,  a  medical  certificate, 
describing  the  mechanical  means  used,  and  stating  the  grounds 
upon  which  the  certificate  is  founded,  be  signed  in  asylums 
and  hospitals  by  the  medical  superintendent,  in  licensed  houses 
by  the  resident  or  visiting  medical  practitioner,  in  workhouses 
by  the  medical  officer,  and  in  the  case  of  single  patients  by 
the  medical  attendant  ;  that  a  full  record  of  every  case  of 
restraint  be  kept  from  day  to  day  ;  and  that  a  copy  of  such 
records  and  certificates  be  sent  to  the  Board  of  Control  at 
the  end  of  every  quarter. 

'  In  framing  this  regulation,  in  which  they  have  defined 
the  "  mechanical  means  "  which  may  alone  be  used  in  the 
imposition  of  lestraint,  the  Board  of  Control  have  merely 
discharged  the  duty  cast  upon  them  by  the  enactment  quoted 
above  ;  and  they  desire  to  guard  themselves  most  strictly 
against  the  supposition  that  they  have  thereby  given  any 
greater  countenance  to  the  employment  of  this  form  of  ti'eat- 
ment  than  they  have  hitherto  shown. 
'  While  recognising,  as  the  enactment  recognises,  the  possible 


TREATMENT  457 

occurrence  of  cases  in  which  its  employment  may  be  necessary 
and  consistent  "s^ith  humanity,  they  remain  of  opinion  that 
the  appHcation  of  mechanical  restraint  should  always  be  re- 
stricted within  the  narrowest  possible  hmits,  that  it  should 
not  be  long  continued  without  intermission,  and  that  it  should 
be  dispensed  ^^'ith  immediately  that  it  has  effected  the  purpose 
for  which  it  was  employed.' 

Suicide. — The  prevention  of  suicide  is  one  of  the  most 
trying  responsibilities  tq  every  physician  and  mnse  whose 
work  is  the  care  and  treatment  of  the  insane.  The  strain  of 
continual  watchfulness  is  at  times  very  severe  and  can  only 
be  fully  realised  by  those  who  have  had  experience  in  such 
nursing.  It  is  necessary  to  foresee  everything  that  the  patient 
may  devise  m  the  way  of  self-destruction,  so  that  his  inten- 
tions can  be  fi'ustrated.  The  nurse  must  be  ever  on  the  alert 
and  for  this  reason  frequent  rehef  is  indispensable.  This 
point  is  not  thoroughly  appreciated,  and  persons  are  apt  to 
think  that  a  nurse  can  go  on  night  and  day  watch 'ng  a  patient. 
Xo  doubt  it  is  a  difficulty  in  nm'sing  patients  in  single  care, 
but  unless  the  relatives  are  willing  to  have  a  sufficient  staff 
of  nm'ses,  a  very  suicidal  patient  should  not  be  treated  in  a 
private  house,  but  should  be  sent  to  an  institution. 

It  is  not  possible  to  enumerate  all  the  precautions  which 
are  necessary,  varying  as  they  do  in  individual  cases,  but  an 
outline  of  the  methods  which  should  be  employed  may  prove 
useful.  The  patient  should  l^e  thoroughly  searched  to  see 
that  nothing  is  secreted  about  his  body  or  clothes.  He  should 
never  be  left  unattended  and  should  be  transferred  from  one 
nurse  to  another.  In  dressing  a  female  patient,  the  hah 
should  be  stitched  up  with  thread  and  no  hah-pins  used. 
Buttons  should  take  the  place  of  tape  on  the  underclothing. 
The  pocket-handkerchief  should  be  kept  by  the  nurse.  The 
food  should  be  cut  and  so  prepared  that  it  can  be  taken 
with  a  spoon.  The  cups  should  be  made  of  thick  porcelain, 
so  that  they  camiot  be  readily  bitten  in  pieces.  The  patient 
should  not  be  allowed  to  go  to  the  lavatory  alone.  .All  keys 
should  be  removed  from  the  bedroom  and  other  doors. 

The  employment  of  suicidal  persons  is  not  easy.  Women 
shoulil  not  l)e  allowed  to  use  scissors,  knitting  needles,  or  other 


458  PSYCHOLOGICAL  MEDICINE 

pointed  instruments.  Thej  may  help  in  dusting  and  tidying 
the  rooms.  Some  patients  will  throw  themselves  downstairs, 
and  it  is  necessary  to  take  every  precaution  when  taking  them 
on  staircases.  Window  sashes  should  be  blocked,  so  that 
they  will  not  open  more  than  a  certain  distance.  Fireplaces 
should  be  protected  by  small  guards.  Out  of  doors  the  patient 
must  be  watched  to  see  that  he  does  not  pick  up  stones,  pieces 
of  glass,  etc.,  and  eat  them.  Hat -pins  are  dangerous  and 
should  not  be  used.  String,  matches,  and  anything  by  which 
a  patient  may  harm  himself  should  be  carefully  kept  out 
of  reach.  At  night  he  should  be  undressed  and  then  searched 
to  see  that  nothing  has  been  secreted  about  him.  The  clothes 
should  be  removed  from  the  room  in  which  the  patient  sleeps. 
It  must  not  be  forgotten  that,  in  spite  of  every  precaution,  a 
person  intent  upon  suicide  may  ultimately  succeed  in  eluding 
even  the  most  constant  and  careful  supervision.  A  patient 
has  been  knoTMi  to  strangle  himself  under  the  bed-clothes 
when  the  nm'se  in  charge  has  been  sitting  beside  him.  Never 
allow  a  suicidal  patient  to  cover  up  his  face  when  in  bed. 

When  recovery  is  taking  place,  much  judgment  is  required 
in  knowing  how  far  to  relax  the  stringent  rules  of  supervision 
which  have  been  necessary  during  the  acute  stage  of  the  Ulness. 
A  great  injustice  may  be  done  to  the  patient  by  not  allowing 
greater  fi-eedom  ;  on  the  other  hand,  if  anything  happens  as 
a  result  of  lessened  supervision,  the  physician  will  be  blamed 
for  his  error  of  judgment.  Certain  risks  must  be  taken  in 
the  interests  of  the  patient,  as  nothing  disheartens  a  person 
so  much  as,  when  feehng  himself  better,  to  find  that  he  is 
not  trusted  ;  and  nothing  gives  him  greater  encom^agement 
than  to  find  that  he  is  being  allowed  more  freedom.  Patients 
when  they  are  recovering  usually  realise  that  the  physician  and 
nurse  have  their  duties  to  perform,  and  if  they  give  a  promise 
not  to  harm  themselves  they  are  generally  to  be  trusted. 

It  is  more  difficult  to  treat  a  suicidal  patient  in  a  private 
house  than  in  an  mstitution  ;  in  the  former  all  rules  seem 
directed  against  the  particular  patient,  while  in  the  latter  the 
regulations  are  of  general  application  and  must  be  conformed 
to  by  all.  As  observed  elsewhere,  there  need  be  no  hesitation 
in  speaking  to  a  patient  upon  his  suicidal  ideas  ;  conversation 
on  the  subject  is  often  far  more  helpful  than  distressing. 


TREATMENT  459 

Homicide. — A  truly  homicidal  person  is  fortunately  not  a 
common  type  of  patient,  but  when  met  with  he  is  a  sore 
responsibility.  Many  patients  may  injure  nurses  or  others 
by  impulsive  violence,  but  he  who  quietly  and  cunningly 
matures  a  plan  of  homicide  is  far  more  dangerous.  He  watches 
his  opportunities  and  may  use  them  with  deadly  effect.  Such 
patients  should  be  placed  where  plenty  of  assistance  is  always 
at  hand,  and  they  should  be  separated  from  other  patients 
whose  tendencies  are  towards  violence.  Concerted  action  is 
rare  in  asylums,  but  when  it  does  occur,  it  is  in  the  homicidal 
class  that  the  originator  is  likely  to  be  found. 

Dangerous  patients  should  be  watched  when  in  the  garden 
lest  they  secrete  any  large  stones  or  other  formidable  weapons 
of  attack.  A  stone  or  a  billiard  ball  in  a  stocking  is  a  very 
favourite  instrument  with  which  to  make  an  assault.  Persons 
of  homicidal  tendency  should  be  placed  under  as  close  super- 
vision as  suicidal  patients  and  should  be  as  frequently  searched. 
Only  a  spoon  should  be  allowed  at  meals  and  it  is  a  wise 
precaution  to  place  them  at  a  small  table  by  themselves.  At 
night,  nurses  should  not  visit  them  singly.  On  recovery 
these  patients  should  be  detained  for  some  little  time  to  see 
that  convalescence  is  complete,  as  too  early  discharge  may 
lead  to  some  tragedy. 

Destmctiveness. — Destructiveness  is  frequently  a  trying 
symptom  in  some  types  of  mental  disorder,  for  a  destructive 
patient  can  do  many  pounds'  worth  of  damage  in  a  very  short 
time.  Some  are  more  inclined  to  destroy  their  own  clothmg  ; 
others  confine  their  attention  to  breaking  furniture  and 
crockery.  If  there  is  a  disposition  continually  to  tear  up 
clothing,  it  is  advisable  to  dress  the  patient  in  some  material 
which  it  is  difficult  or  impossible  to  destroy  ;  this  garment 
should  be  an  outer  garment,  the  ordinary  underclothing  being 
worn  as  usual.  The  furniture  and  all  the  vessels  used  for 
feeding  should  be  very  strong,  and  many  patients  will  abandon 
attempts  to  destroy  when  they  prove  uniformly  unsuccessful. 

Moral  Treatment. — What,  for  the  want  of  a  better  term, 
may  be  called  the  moral  treatment  of  the  insane  will  be  found 
to  be  a  most  potent  remedy  in  the  hands  of  a  skilled  physician. 
The  personality  of  those  with  whom  we  are  constantly  thro^vn 
in  contact  influences  us  in  no  small  degree.     Even  when  we 


460  PSYCHOLOGICAL  MEDICINE 

are  in  robust  health  we  are  attracted  or  repelled  by  different 
persons  ;  we  trust  one  man,  and  distrust  another  ;  we  feel 
that  we  are  understood  by  one,  misunderstood  by  another  ; 
we  are  unconsciously  swayed  by  the  thoughts  and  suggestions 
of  some  men,  while  the  ideas  of  others  are  unheeded,  not 
necessarily  because  they  are  distasteful,  but  because  they  do 
not  carry  force  and  conviction  with  them. 

Now  if  this  is  the  case  with  the  healthy  mind,  how  much 
more  must  the  person  with  a  diseased  mind  lean  upon  the 
thoughts  and  help  of  others.  Some  physicians  and  nm'ses 
have  the  natural  gift  of  inspiring  their  patients  with  hope  and 
trust.  The  sick  man  is  the  better  for  seeing  them,  their  visits 
seeming  to  imbue  him  with  renewed  hfe.  The  physician  is 
apt  to  forget  how  closely  the  patient  watches  liim  and  what 
importance  is  attached  to  all  that  he  says  ;  he  at  times  forgets 
that,  Avhen  the  visit  is  concluded,  the  patient  will  revolve  over 
and  over  again  in  his  mind  all  that  has  passed.  Patients  do  not 
beheve  all  that  they  are  told  ;  but  of  two  physicians  express- 
ing the  same  opinion,  the  one  will  carry  conviction  by  his 
personality  and  be  beheved,  while  the  other,  through  lack  of 
sympathy,  will  simply  be  listened  to  and  disbelieved.  Never 
forget  that  the  insane  man  should  be  treated  as  an  ordinary 
patient  and  always  listen  to  what  he  has  to  say. 

The  physician  who  would  be  successful  in  the  treatment  of 
mental  disease  must  have  many  attributes,  and  it  is  well 
for  him  that  he  should  learn  this  while  he  is  still  young,  as 
the  necessary  qualities  may  take  j^ears  to  acquire.  Patience 
must  be  learned,  for  of  all  people  the  insane  are  the  most 
trying.  Without  patience  the  treatment  of  mental  disease  must 
be  to  a  great  extent  a  failure,  as  the  impatient  physician  wearies 
himself,  while  producing  little  or  no  good  on  the  man  he  seeks 
to  benefit.  Another  secret  of  success  is  the  ability  to  impress 
the  patient  with  the  interest  that  you  take  in  his  case.  This 
faculty  of  showing  interest  and  enthusiasm,  which  moreover 
should  be  real  and  not  feigned,  is  of  intense  value ;  it  never 
fails  to  infuse  into  the  patient  a  sense  of  conlidence  and 
assurance  that  his  complaint  is  understood. 

Instructions  as  to  treatment  must  be  given  in  an  unequivocal 
manner.  Firmness  is  a  necessary  attribute,  but  only  so  far  as 
the  proper  conduct  of  the  case  is  concerned.     Concessions  on 


TREATMENT  461 

unimportant  matters  often  save  much  unnecessary  friction  and 
render  the  patient  more  tractable,  as  he  feels  that  he  is  not 
dictated  to  on  all  points.  Never  allow  the  patient  to  get  the 
upper  hand,  and  let  him  clearly  understand  that  he  is  under 
medical  orders  and  that  all  questions  must  be  decided  b}^  the 
physician.  The  medical  attendant,  on  the  other  hand,  knowing 
his  power,  should  be  exceptionally  careful  not  to  misuse  it. 
Kindness  and  thoughtfulness  for  the  feehngs  of  the  patient  are 
always  appreciated  by  the  invalid  and  go  a  long  way  towards 
making  the  relationship  between  him  and  his  physician  cordial 
and  pleasant.  All  grievances  should  be  patiently  listened  to 
and  investigated.  Do  not  jump  to  the  conclusion  that  the 
patient  is  in  the  wrong  without  giving  him  a  fair  hearing  ; 
but  if,  after  listening  to  all  he  has  to  say,  you  consider  that 
he  is  mistaken,  do  not  hesitate  to  tell  him  so  and  give  him 
your  reasons  for  coming  to  such  a  conclusion. 

Treat  the  insane  as  if  they  were  sane.  Never  promise  to 
do  a  thing  which  you  know  you  will  be  unable  to  fulfil.  You 
may  frequently  have  to  disagree  with  the  views  of  your  patient ; 
by  all  means  do  so  when  necessary,  but  do  it  in  a  kindly  way, 
explaming  to  him  that  it  is  only  for  a  time  that  he  has  to 
put  up  with  medical  supervision,  and  that  you  will  be  as 
pleased  as  he  is  when  once  more  he  is  able  to  take  up  the 
direction  of  his  o^ti  affairs.  Let  him  discuss  his  delusions 
with  you  and  try  to  point  out  the  errors  that  he  makes.  It 
is  only  after  much  experience  that  the  physician  will  know 
what  attitude  to  adopt  in  any  given  case.  You  can  smile  at 
the  ideas  of  one  man  and  almost  joke  him  out  of  his  fears, 
while  another  would  deeply  resent  any  such  flippancy. 

Correction  may  be  necessary  in  some  cases,  especialh^  in 
those  patients  who  do  things  wilfully,  just  to  annoy  fellow- 
patients  or  the  nurses.  The  punishment  of  such  persons 
has  frequently  been  the  subject-matter  of  papers  and  dis- 
cussions, the  opinion  of  authorities  being  divided  upon  the 
question.  AVhatever  is  done  should  not,  in  the  opinion  of 
the  writer,  be  done  in  the  form  of  punishment.  The  patient 
must  leam  that  unless  he  obeys  the  rules  laid  down  for  the 
general  welfare,  exceptional  regulations  will  have  to  be  made 
to  meet  his  special  case.  Food  should  never  be  limited  in 
the  treatment  of  the  vicious,  for  to  put  a  patient  on  bread  and 


462  PSYCHOLOGICAL  MEDICINE 

water  is  to  defeat  the  ends  which  the  physician  has  in  view. 
Luxuries  and  pleasures  can  be  stopped,  even  with  benefit  to 
the  individual,  apart  from  any  desire  to  punish. 

Patients  should  be  encouraged  to  employ  themselves,  and 
even  if  they  do  not  feel  incHned  to  read,  let  them  make  use  of 
their  hands.  It  must  not  be  forgotten  that  many  persons  fail 
to  occupy  themselves,  not  because  they  do  not  want  to  work, 
but  because  they  cannot  keep  their  attention  fixed  upon  any 
one  thing  for  more  than  a  moment  at  a  time.  As  we  have 
already  pointed  out,  inattention  is  the  cause  of  much  inaction, 
and  it  is  useless  to  urge  patients  to  work  so  long  as  the  effort 
of  concentrated  attention  is  too  great  for  them.  Light  em- 
ployment, such  as  helping  in  the  dusting  of  rooms  or  similar 
occupations,  is  useful  in  passing  time  ;  a  conscientious  nurse 
■v^all  often  succeed  in  persuading  a  patient  to  assist  in  work 
of  this  kind.  Outdoor  exercise  is  also  good  and  is  more 
congenial  than  indoor  occupation  in  many  cases. 

The  surroundings  of  the  hospital  or  home  should  be  cheerful 
and  the  nm'ses  of  bright  disposition.  A  pleasant  environ- 
ment will  often  go  a  long  way  in  helping  some  patients  to 
get  well,  as  it  instils  new  vigour  into  them  and  gives  them 
the  feeling  that  after  all  hfe  is  not  all  pain  and  sorrow. 
There  are  many  persons  whose  mental  disorder  is  the  result 
of  a  hard  and  self-denying  hfe,  and  to  them  cheerful  surround- 
ings are  peace  to  mind  and  body.  The  disposition  of  circum- 
stances is  not  everything.  Disease  is  not  stayed  by  comforts 
and  luxury,  but  we  are  creatures  easily  affected  by  gloom  or 
sunshine,  by  harshness  or  hj  sympathy. 

Psycho-therapeutics.- — Dm-ing  recent  years  this  form  of 
treatment  has  been  greatly  discussed.  No  doubt  it  contams 
in  essence  much  that  has  been  practised  before,  nevertheless 
it  must  be  conceded  that  the  subject  is  now  being  dealt  with 
on  far  more  scientific  lines  and  not  in  the  haphazard  methods 
which  were  formerly  in  vogue. 

It  would  be  impossible  in  a  book  of  this  kind  to  do  justice 
to  this  subject,  and  all  the  writer  can  attempt  to  do  will  be 
to  refer  briefly  to  the  various  systems  of  psycho-therapeutics 
in  use  at  the  present  time.  Modem  investigation  has  shown 
us  that  mental  troubles  may  have  a  mental  origin  and  there- 
fore they  can  only  be  effectively  removed  by  psychic  means. 


TREATMENT  463 

We  kiiow  that  sensations  tend  to  become  associated  with  other 
sensations  and  the  rising  into  consciousness  of  one  sensation 
may  be  instantly  followed  by  other  sensations  or  ideas  (which 
are  the  mental  images  of  former  sensations)  that  have  become 
associated  with  it.  Many  of  the  phobias  are  of  this  kind.  This 
grouping  together  of  associated  ideas,  sensations,  feelings  and 
visceral  or  somatic  disturbances,  etc.,  in  such  a  way  that  the 
stimulation  of  one  element  in  the  group  sets  in  activity  the 
rest  of  the  group,  is  usually  spoken  of  as  a  constellation  of 
ideas,  and  when  such  a  constellation  is  repressed  or  partly 
unconscious,  it  is  known  as  a  '  complex.'  Of  course  such  a 
grouping  may  form  a  complex  which  is  of  advantage  to  the  well- 
being  of  the  organism,  and  here  the  complex  is  spoken  of  as 
a  normal  one  ;  when  the  action  is  harmful,  it  is  abnormal. 
Now  in  this  latter  case  to  break  up  the  complex  and  dissociate 
the  mental  factors  of  which  it  is  composed  frequently  leads  to 
the  re-establishment  of  the  patient's  health.  There  are  various 
methods  whereby  psycho-therapy  can  be  practised  : 

1.  Therapeutic  Conversation. 

2.  Psycho-analysis. 

3.  Occupation. 

4.  Suggestion,  including  hypnosis. 

5.  Ee-education. 

1.  Therajpeutic  Conversation  is  no  doubt  a  new  name  for 
an  old  method  of  treatment,  but  Dubois  has  greatly  elabor- 
ated this  method.  It  consists  in  patiently  listening  to  the 
invalid's  account  of  himself  and  explaining  to  him  the  origin 
and  significance  of  his  symptoms.  If  he  has  a  phobia, 
show  him  step  by  step  how  the  complex  was  formed  ;  and  if 
you  succeed  in  convincing  him,  either  by  the  clearness  of 
your  argument,  or  by  his  faith  in  the  power  at  your  disposal, 
or  by  his  behef  in  you  as  a  physician,  the  so-called  cure 
may  appear  almost  miraculous.  It  is  the  unknown  that 
fills  the  timid  with  fear ;  or  the  explanations  which  th,e 
patient  has  already  evolved  to  account  for  his  symptoms 
may  have  depressed  him  far  more  than  the  original  disorder, 
and  to  ^remove  them  often  goes  a  long  way  in  promoting 
recovery. 

2.  Psyclio-analysis. — It  is  largely  to  Freud  that  we  owe  this 


iG-l  PSYCHOLOGICAL  MEDICINE 

method  of  exammation.  He  believes  that  the  cause  of  soiiio 
types  of  mental  disorder  is  the  early  repression  of  certain 
wishes  and  deskes  in  childhood,  and  that  in  some  way  these 
have  been  repressed  out  of  consciousness,  and  yet,  owing  to 
their  dynamic  energy,  they  are  able  to  influence  and  disturb 
both  feeling  and  thought  and,  indirectly,  our  functional  activi- 
ties. The  subject  is  far  too  large  a  one  for  the  writer  to  do 
justice  to  in  a  short  paragraph,  iDut  briefly  it  is  as  follows  : — 

The  aim  of  the  phj^sician  is  to  find  out  what  is  being  re- 
pressed and  again  synthesise  it  to  the  normal  self.  Complexes 
of  the  kind  referred  to  usually  have  been  the  result  of  a 
'  conflict  '  between  two  groups  of  ideas  which  are  out  of 
harmony  -^^ith  or  repel  each  other  ;  finally  one  overcomes  and 
the  other  is  held  back  or  repressed,  and  the  resistance  which 
controls  it  is  spoken  of  as  the  '  censor.' 

Freud's  method  of  investigation  is  of  three  kinds  :  {a) 
dream  analysis  ;    (b)  free  association  ;    (c)  word  association. 

(a)  Dreams  consist  of  the  '  manifest '  and  '  latent  '  contents. 
The  former  is  the  obvious  connection  of  the  dream  with  the 
recent  events  in  waking  life  ;  the  latter  requires  interpretation, 
and  is  usually  regarded  hy  Freud  as  the  imagined  fulfilment 
of  an  unconscious  wish. 

It  is  to  this  latent  content  that  the  psycho-analyst  directs 
his  attention.  During  sleep  the  censorship  is  partially  relaxed 
and  the  dreamer  is  allowed  to  gratify  unconscious  desires  pro- 
vided the  repressed  wishes  are  hidden  by  bizarre  symbolism, 
and  it  is  the  distortion  of  the  dream  which  evades  the  censor, 
otherwise  waking  would  take  place. 

The  mechanisms  of  distortion  are  four  in  number  : — 

(!)  Disflacemeyit. — The  apparently  unimportant  details  of 
a  dream  are  often  the  most  significant. 

(2)  Condensation. — The  element  of  a  dream  represents  not 
one  but  a  number  of  unconscious  thoughts  fused  into  one 
conscious  tliought. 

(3)  Symholisation. — According  to  Freud,  symbols  are  largely 
a  cloak  for  some  sexual  idea. 

(4)  Dramatisation. — Incidents  frequently  are  presented  in 
a  dramatic  form  ;  all  events  appear  to  take  place  in  the 
present,  no  matter  how  remote  in  reality. 

If  there  is  an  emotional  tone  attached  to  any  percept  in  a 


TREATMENT  4G5 

clieam,  it  is  correct  and  not  distorted.  Further,  dreams  are 
always  egoistic  and  the  dreamer  is  the  chief  actor  even  if  he 
fails  to  grasp  the  fact  himself. 

[h)  Free  association  is  conducted  by  placing  the  subject  in 
quiet  surroundings,  and  he  is  told  to  relate  without  reserve  and 
without  comment  the  various  thoughts  as  they  arise  in  con- 
sciousness. Whilst  he  is  talking  the  observer  often  will  come 
across  '  resistances,'  which  are  an  attempt  to  prevent  the 
disclosure  of  some  complex  either  to  the  observer  or  to  the 
patient  himself. 

(c)  Word  association,  or  time  reaction  experiment.  Lists 
of  selected  words '  are  taken.  The  observer,  stop-watch 
in  hand,  asks  the  patient  to  give  the  first  word  he  thinks  of 
after  the  experimenter  has  given  a  word  ;  the  time  is  noted  as 
to  how  many  seconds  elapse  between  the  patient's  receiving 
the  word  and  giving  his  associated  word.  The  time  varies 
from  2  to  8  seconds.  The  average  time  for  each  word  is  about 
3  seconds  ;  on  the  other  hand,  some  responses  are  given  more 
rapidly,  others  more  slowly.  These  are  the  words  which  are 
of  account  and  to  which  the  analyst  looks  for  giving  him  help 
in  his  analysis.  After  the  investigation  is  complete  and  the 
patient  has  become  aware  of  the  cause  of  his  disorder,  he  is 
assisted  to  accept  a  wider  mental  association  to  the  idea  con- 
nected with  the  originally  repressed  desire.  In  this  way  it 
is  asserted  that  the  tendency  for  further  repression  will  be 
overcome,  and  there  is  a  '  sublimation  '  of  the  pent-up  energy 
inio  some  uselul  channel. 

Psycho-analysis  is  chiefly  of  value,  according  to  Freud, 
in  the  examination  and  treatment  of  the  psycho-neuroses, 
whereas  the  actual  neuroses  can  neither  be  explamed  nor  reduced 
by  this  method.  The  psycho-neuroses,  according  to  him,  are 
in  tliree  main  groups  :  (a)  hysteria  ;  (&)  phobise  ;  (c)  the 
obsessional  nem'oses. 

The  main  criticism  of  the  Freudian  interpretation  is  un- 
doubtedly directed  against  his  theory  of  the  sexual  function. 
He  has  endeavoured  to  prove  that  infantile  and  childhood 
phantasies  and  desires,  which  he  believes  are  of  a  sexual 
nature,  are  the  cause  of  subsequent  psycho-neurotic  symptoms 
in  adult  Hfe.  As  a  method  of  research  psycho-analysis  has  its 
place,  and  no  doubt  an  important  place,  if  carried  out  by 

30 


466  PSYCHOLOGICAL  MEDICINE 

highly  experienced  investigators,  and  one  must  go  further  and 
say  that  it  has  gone  a  long  way  towards  explaining  the  probable 
origin  of  certain  mental  symptoms.  It  has  emphasised  the 
effect  that  repressed  thought  and  desire  may  have  upon  the 
immediate  and  future  mental  life  of  an  indi"vddual.  On  the 
other  hand,  as  a  method  of  treatment  there  is  much  to  be  said 
against  it.  Apart  from  being  peculiarly  objectionable,  it  is 
fraught  with  no  small  dangers,  and  frequently  it  not  only  fails 
to  reUeve  the  patient  but  leaves  him  in  a  far  more  distracted 
state. 

It  is  a  treatment  which  does  not  tend  to  elevate  thought ; 
consider  for  one  moment  and  think  where  it  leads  you.  Where 
is  the  good  to  tell  a  young  mimarried  man  or  woman  that 
such  and  such  nervous  symptoms  are  due  to  ungratified 
sexual  desire  ?  It  is  distressing  to  the  upright  and  suggesting 
temptation  to  the  weak.  The  interpretation  of  the  so-called 
symbols  is  frequently  far  from  convincing  and  strongly  suggests 
an  effort  on  the  part  of  the  interpreter  to  support  a  precon- 
ceived judgment.  The  Avriter  is  aware  that  this  is  denied 
by  the  followers  of  Freud  and  that  theoretically  the  patient 
can  work  out  his  own  sublimation,  but  the  theory  would 
appear  not  uncommonly  to  break  down  in  practice.  Again, 
even  if  it  is  true  that  buried  desires  are  the  cause  of  psycho- 
neuroses,  and  the  arguments  in  proof  are  far  from  convincing, 
why  should  the  renewed  knowledge  of  them  be  a  necessary 
factor  for  the  discharge  of  these  complexes  ?  There  is  one 
and  only  one  condition  which  would  permit  the  general  use 
of  Freudian  methods,  which  methods  to  the  lay  mind  must 
ever  be  sordid,  and  that  is  the  absolute  certainty  that  they 
are  right.  At  the  moment  the  usefulness  of  psycho-analysis 
as  a  curative  measure  is  by  no  means  proved. 

3.  Occupation. — In  most  forms  of  mental  disorder  it  is  all- 
important  that  the  patient  should  have  absolute  rest  from 
all  work.  Nevertheless  there  are  some  cases,  especially  those 
belonging  to  the  congenital  neurasthenic  type,  in  which  too 
much  rest  is  bad,  and  if  care  is  not  exercised  he  will  add 
the  bed-habit  to  the  other  bad  habits  he  has  formed.  In 
these  cases  regulated  work  of  an  interesting  kind  should  be 
prescribed.  The  learning  of  a  foreign  language  and  some 
manual  occupation  may  prove  invaluable  in  the  treatment. 


TREATMENT  -  467 

Also  patients  who  feel  that  they  and  the  things  about  them 
are  unreal  may  find  this  sense  of  unreality  die  away  before 
new  interests. 

4.  Suggestion  is  now  divided  into  three  classes  :  (a)  Waking, 
(&)  hypnoidal,  (c)  hypnotic.  They  all  have  their  uses,  and 
at  times  this  method  of  treatment  is  most  successful.  The 
writer  has  found  that  persons  suffering  from  certain  types  of 
alcohoHsm  and  a  small  percentage  of  psychastheniacs  are 
peculiarly  susceptible  to  improvement  by  suggestion.  But 
it  must  be  borne  in  mind  that  unless  this  treatment  is 
followed  up  by  some  system  of  re-education  there  is  a  grave 
danger  of  relapse.  Just  as  the  habit  was  originally  acquired 
so  it  may  be  acquired  again. 

5.  Be- education. — This  ought  to  be  the  final  stage  of  what- 
ever methods  have  been  employed.  It  is  the  duty  of  the 
physician  to  teach  the  patient  to  understand  himself  and 
to  appreciate  his  limitations.  Teach  him  what  he  has  done 
wrong  in  the  past,  whether  this  be  in  his  mode  of  work,  his 
recreation,  his  appetites,  his  habits  of  thought,  etc.  If  he  has 
been -the  subject  of  some  overwhelming  fear,  show  him  how 
it  arose  and  how  he  built  it  up,  and  point  out  how  phobias 
are  to  be  overcome.  The  great  hope  of  re-education  lies  in 
its  prophylactic  power ;  former  habits  are  replaced  by  new 
ones  and  the  old  associations  which  were  harmful  are  broken 
up,  and  in  their  stead  complexes  are  formed  which  are 
beneficial  to  the  mental  and  physical  health  of  the  patient. 

In  conclusion,  before  leaving  this  subject  we  must  remind 
the  reader  that  mental  therapy  must  not  be  divorced  from 
physical  therapy  ;  psycho-therapeutics  in  reality  is  merely  a 
widening  of  the  powers  of  medicine. 

The  recent  development  of  psychological  laboratories  in 
the  various  Universities  indicates  the  trend  of  events. 
Psychology  is  being  placed  on  a  more  scientific  basis  and 
experimentation  is  correcting  and  augmenting  the  old 
metaphysical  and  purely  theoretical  formulae. 

Correspondence. — The  question  of  letter- writing  is  one  that 
will  usually  have  to  be  decided  by  the  physician.  Some 
patients  will  write  countless  letters  ;  others  will  not  even  put 
pen  to  paper.  To  most  persons  letter-writing  is  an  effort 
and   accordingly  is   early  given   up   with   any   illness.      The 


468  PSYCHOLOGICAL  MEDICINE 

relatives  of  the  patient  are  often  foolish  in  urgmg  him  to 
write,  thinking  that  it  cannot  fail  to  do  him  good  and  help 
him  to  decentrahse  his  thoughts.  This  error  must  be  cor- 
rected, and  definite  instruction  must  be  given  that  the  patient 
need  not  write  letters  unless  he  desires  to  do  so.  It  is  both 
harmful  and  painful  for  a  man  to  sit  for  hours  over  a  sheet 
of  paper  trying  to  compose  a  letter,  and  his  ultimate  failm^e  is 
disappointing  to  him.  When  a  patient  recovers,  he  will  soon 
take  a  pleasure  in  once  again  writmg  to  his  friends. 

When  convalescence  is  established,  it  is  often  advisable  to 
urge  an  individual  to  do  something,  so  that  he  may  slowly 
gain  confidence  in  himself.  If  he  writes  under  these  circum- 
stances, let  the  correspondence  at  first  be  quite  short,  the 
letter  consisting  of  a  few  Hnes  only.  As  a  general  rule  there 
is  no  harm  in  the  friends  of  a  patient  writing  to  him,  pro- 
vided that  they  are  wise  in  what  the}^  write,  and  that  they 
are  careful  not  to  touch  upon  any  worrying  topic.  It  is  very 
harmful  for  a  patient  to  receive  a  note  filled  with  distress- 
ing details  of  any  domestic  or  financial  difficulties,  and  such 
letters  have  been  known  to  provoke  intensely  suicidal  tenden- 
cies. The  ignorance  of  laymen  regarding  mental  disease  is  so 
great  that  they  will  often  persuade  themselves  that  the  patient 
can  get  well  if  he  will  only  try,  and  they  accordingly  believe 
that  if  they  only  paint  a  sad  enough  picture  of  the  family 
distress,  it  will  urge  the  man  to  shake  off  his  malady.  Such 
persons  must  be  taught  that  mental  disease  can  no  more  be 
removed  by  an  effort  of  the  will  than  any  other  illness  to 
which  man  is  heir.  With  regard  to  the  letter- writing  of  persons 
who  are  mider  certificates,  their  correspondence  is,  to  a  certain 
extent,  supervised  by  the  physician  in  whose  care  the  patients 
are  placed.  This  arrangement  is  entirely  in  the  interests  of 
the  patient,  for  it  is  thus  possible  to  stop  letters  written  to 
business  houses  or  to  individuals  with  whom  it  is  not  expedient 
for  him  to  correspond. 

The  Hmits  of  these  supervisionary  powers  are  defined  in 
the  Lunacy  Act,  1890  ;  letters  addressed  to  certain  persons 
have  to  be  forwarded  unopened.  For  the  convenience  of  the 
reader,  a  copy  of  the  section  of  the  Lunacy  Act  relating  to  the 
correspondence  of  patients  is  here  appended. 


TREATMENT  469 

'  Sect.  41,  Lunacy  Act,  1890 

'  (1)  The  manager  of  every  institution  for  lunatics,  and 
every  person  having  charge  of  a  single  patient,  shall  forward 
unopened  all  letters  written  by  any  patient  and  addressed  to 
the  Lord  Chancellor,  or  any  Judge  in  Lunacy,  or  to  a  Secre- 
tary of  State,  or  to  the  Commissioner,  or  any  Commissioners, 
or  to  the  person  who  signed  the  order  for  the  reception  of  the 
patient,  or  on  whose  petition  such  order  was  made,  or  to  the 
Chancery  Visitors  or  any  Chancery  Visitor,  or  to  any  visitor 
or  visitors,  or  to  the  visiting  committee  or  any  members  of 
the  visiting  committee  of  the  institution  in  which  any  patient 
writing  such  letters  may  be,  and  may  also,  at  his  discretion, 
forward  to  its  address  any  other  letter,  if  written  by  a  private 
patient. 

'  (2)  Every  manager  of  an  institution  for  lunatics,  and 
every  person  having  charge  of  a  single  patient,  who  makes 
default  in  complying  with  this  obhgation  imposed  on  him  by 
this  section,  shall  for  each  offence  be  liable  to  a  penalty  not 
exceeding  twenty  pounds.' 

Visits  of  Friends. — The  visiting  of  a  patient  by  his  friends 
is  one  of  the  greatest  difficulties  the  physician  has  to  encounter 
in  the  treatment  of  insanity.  In  the  first  place,  the  vast 
majority  of  persons  are  inclined  to  treat  with  suspicion  all 
individuals  whose  work  in  life  is  the  care  and  treatment  of 
the  mentally  afflicted.  Thus,  advice  that  relatives  should 
refrain  from  visiting  a  patient  is  often  misconstrued  and 
confirms  them  in  their  belief  that  the  aim  and  object  of  the 
physician  is  to  get  the  patient  isolated  from  his  friends  for 
his  own  purposes.  This  unfortunate  distrust  renders  the 
proper  treatment  of  the  insane  very  difficult.  The  feeling  of 
irritation  which  these  baseless  suspicions  engender  in  the  mind 
of  an  assiduous  and  sympathetic  physician  is  not  lessened  by 
the  knowledge  that  far  greater  kindness  and  consideration 
are  being  bestowed  upon  the  patient  than  he  was  receiving 
in  his  own  home. 

Now  visiting  may  sometimes  be  beneficial,  but  frequently 
it  is  harmful.  The  recovery  of  some  persons,  which  promises 
to  be  rapid  during  isolation  from  their  home  surroundings, 
is  apt  to  be  retarded  by  visits  from  their  friends.  It  is  only 
by  experience  that  distinction  can  be  drawn  between  the  case 


470  PSYCHOLOGICAL  MEDICINE 

which  may  be  visited  with  impunity  and  that  which  will 
make  greater  progress  if  the  home  relationship  is  entirely 
broken  off  for  some  months.  "\^Tien  visiting  is  permitted, 
care  must  be  exercised  that  it  is  done  wisely,  that  the  patient 
is  not  wearied  by  long  conversations,  nor  agitated  by  worrying 
news.  He  is  unable  to  work  or  help  his  family  ;  it  is  there- 
fore a  gi'eat  mistake  to  distress  him  with  troubles  which  he 
can  neither  prevent  nor  alleviate. 

Most  people  have  an  idea  that  they  know  exactly  how  to 
treat  the  insane  ;  they  believe  that  if  only  this  or  that  were 
done  a  certain  cure  w'ould  result.  Now  these  well-meaning 
but  usually  injudicious  persons  will  frequently  seize  an  oppor- 
tunity when  visiting  a  patient  to  practise  their  remedy  upon 
him.  The  result  may  be  disconcerting  to  the  operator,  who 
finds  that  the  effect  on  the  patient  was  not  exactly  that 
which  he  expected  ;  but  this  is  of  small  importance  compared 
with  the  harm  done  to  the  patient  and  the  interruption  in  a 
favom'able  recovery  which  may  result  from  such  practices.  A 
wise  friend  can  do  much  good  by  his  visits,  but  a  foolish  one 
gi'eat  harm. 

Parole. — There  is  probably  nothing  so  much  appreciated  by 
a  patient  as  permission  to  go  out  walking  by  himself.  In  many 
cases  the  granting  of  parole  is  a  most  beneficial  form  of  treat- 
ment, for  it  gives  a  sense  of  greater  liberty  and  a  feeling  that 
he  is  trusted  and  that  his  word  is  believed.  Many  of  the  insane 
and  most  persons  who  are  convalescing  from  a  mental  illness, 
have  a  high  sense  of  honour,  and  if  they  undertake  to  obey 
any  imposed  conditions,  they  can  be  relied  upon  faithfully  to 
fulfil  their  promise.  Indeed,  the  insane  are  often  more  punc- 
tilious than  the  sane  in  strictly  carrying  out  their  pledged  word. 

Religious  Services. — Most  of  our  large  institutions  have  a 
chaplain  especially  appointed  to  conduct  the  religious  services 
of  the  hospital  or  asylum  and  in  other  ways  to  administer 
to  the  spiritual  wants  of  the  inmates.  It  is  better  for  some 
patients,  especially  those  suffering  from  certain  forms  of  melan- 
cholia, not  to  attend  church  services,  as  they  usually  increase 
the  agitation.  Unless  especially  contra-indicated,  the  reli- 
gious services  are  often  a  useful  adjunct  to  the  general  treat- 
ment, and  a  wise  chaplain  can  do  much  good  in  alleviating 
the  mental  suffering  of  some  patients. 

Special  Duties  o£    the  Nurses. — It  is  impossible    to  enter 


TREATMENT  471 

fully  into  the  various  duties  which  the  nurses  of  the 
insane  are  expected  to  carry  out,  and  for  information  on 
these  matters  reference  must  be  made  to  books  specially 
devoted  to  the  subject.  Much  caution  must  be  exercised 
in  the  choice  of  nurses,  and  at  all  times  they  should  be 
carefully  supervised.  Nurses  tending  the  insane  require 
exceptional  tact,  as  they  have  to  exercise  certain  authority 
without  appearing  to  do  so.  They  must  note  any  changes 
in  their  patient  and  report  them  to  the  medical  attendant. 
Suicidal  or  homicidal  attempts,  however  slight,  should 
be  reported  at  once.  Careful  note  must  be  made  of  the 
daily  actions  of  the  patient's  bowels  ;  the  regular  passing 
of  urine  must  not  be  overlooked  and  attention  should 
be  drawn  at  once  to  cases  of  retention.  When  possible,  all 
patients  who  are  acutely  ill  should  have  their  temperature 
taken  morning  and  evening,  and  this  is  of  special  importance 
in  cases  of  general  paralysis.  All  marks,  bruises,  or  other 
unusual  external  appearances  should  be  reported.  Eefusal  of 
food  should  be  noted  at  once.  A  refractory  patient  should  not 
be  handled  by  one  nurse  ;  sufficient  assistance  should  always 
be  ready  if  required  in  dealing  with  these  cases,  for  some 
patients  will  struggle  or  fight  with  one  or  two  nurses,  but  will 
give  no  trouble  if  other  help  is  at  hand.  No  nurse  should  be 
left  in  charge  of  an  anxious  suicidal  patient  for  many  hours 
without  being  relieved,  as  the  strain  of  watching  these  cases 
is  very  great. 

Drugs. — Drugs,  apart  from  narcotics,  hold  a  similar  posi- 
tion in  the  treatment  of  mental  disease  to  the  administration 
of  medicine  in  cases  of  physical  disorder.  Sound  advice 
and  general  direction  as  to  how  the  patient  should  live  must 
hold  the  first  position  in  the  treatment  of  most  complaints, 
but  drugs  are  a  useful  adjmict  to  the  resources  of  the  physician 
when  practising  his  heahng  art.  There  are  some  medicines 
with  which  it  would  be  impossible  to  dispense  in  the  treatment 
of  ce]:tain  diseases,  but  drugs  with  a  specific  action  are  not 
numerous.  Nevertheless,  all  physic  can  be  used  with  effect 
in  the  hands  of  a  skilful  physician,  for  just  as  the  patient 
may  place  unbomided  faith  in  the  power  of  his  medical  atten- 
dant, similarly  the  medicine  that  he  prescribes  usually  becomes 
endowed  with  special  merits. 

The  traditional  belief  in  the  curative  powers  of  physic  is 


472  PSYCHOLOGICAL  MEDICINE 

still  deeply  ingrained  in  the  human  mind.  With  the  spread 
of  general  knowledge  and  education,  the  public  are  slowly 
learning  that  drugs  alone  will  not  heal,  but  that  the  physician's 
advice  also  must  be  followed.  Nevertheless,  the  majority  of 
persons  consider  that  it  is  the  medicine  that  cures,  the  wisdom 
of  the  medical  attendant  being  shown  by  his  acumen  in  diagnosis 
and  liis  selection  of  the  appropriate  drug.  The  natural  tendency 
of  all  tissues  to  recover  is  not  understood  by  the  lay  mind, 
the  phj^'sician  and  his  pharmaceutical  store  being  the  agents 
to  which  they  look  for  relief.  Many  persons  when  they  are 
told  that  they  must  give  up  this  or  that,  or  in  other  ways 
change  their  mode  of  living,  are  far  from  satisfied  with  the 
advice  ;  for  they  do  not  want  to  change  their  habits,  but 
desire  something  to  counteract  their  vicious  tendencies.  Drugs 
are  the  outward  and  visible  sign  of  the  physician's  mystic 
powers,  and  in  most  instances  it  is  wiser  to  give  something, 
even  if  it  is  only  a  general  tonic,  as  the  man  who  is  taking 
medicine  is  always  more  willing  to  follow  other  advice. 

This  belief  in  medicine  is  apt  to  be  forgotten  by  the  medical 
officers  of  institutions  and  especially  by  those  whose  work  is 
in  asylums.  The  use  of  drugs  merely  for  appearance'  sake  is 
not  of  course  to  be  advocated,  but  there  are  plenty  of  remedies 
the  action  of  which  is  usually  beneficial  in  bringing  about  an 
improvement  in  the  blood  or  general  nutrition  of  the  body. 
When  no  specific  drugs  are  indicated,  these  simpler  remedies 
may  be  properly  employed,  as,  apart  from  their  immediate 
effect  upon  the  economy  of  the  organism,  they  not  infrequently 
act  by  '  suggestion,'  and  at  least  relieve  the  patient's  mind  by 
the  knowledge  that  every  effort  is  being  made  to  promote  his 
recovery.  • 

Again,  it  is  wise  to  make  the  treatment  of  mental  disease 
resemble  as  closely  as  possible  the  treatment  of  disease  in 
general.  It  is  important  that  the  insane  man  should  regard 
his  condition  as  one  of  ordinary  illness,  which  it  is  in  reality, 
and  therefore  methods  of  treatment  should  be  of  the  kind 
usually  employed. 

The  first  endeavour  should  be  to  improve  the  physical 
condition  of  the  patient.  Iron,  arsenic,  maltine,  malt  and 
cod  liver  oil,  compound  syrup  of  hypophosphites,  Easton's 
syrup,   Parrish's   food,   acids,    bitters,   etc.,   are   all  valuable 


TREATMENT  473 

medicines  in  the  treatment  of  mental  disorder.  If  the  patient 
is  suffering  from  any  definite  physical  disease,  this  must  be 
prescribed  for,  as  the  mental  disorder  is  not  uncommonly 
merely  a  complication  of  that  physical  disease. 

Opium  and  its  alkaloids  are  helpful  in  the  treatment  of 
some  forms  of  insanity,  but  their  usefulness  is  limited  and 
their  value  is  apt  to  be  over-estimated.  They  are  contra- 
indicated  in  many  forms  of  excitement.  At  times  the  ad- 
ministration of  opium  greatly  increases  the  mental  agitation 
of  a  patient,  while  at  others  it  exercises  a  sedative  influence. 

Hyoscin  and  hyoscyamin  are  drugs  which  are  largely  used 
by  some  authorities.  They  act  by  paralysing  the  nerve- 
endings  in  the  muscles,  and  in  this  way  they  lessen  restless- 
ness in  a  maniacal  patient.  To  paralyse  the  muscles  does 
not  necessarily  allay  mental  excitement  in  the  individual ;  it 
doubtless  produces  an  appearance  of  rest  by  preventing  violent 
muscular  action  and  it  confers  a  period  of  peace  on  those 
with  whom  the  patient  is  associated.  The  use  of  hyoscin  or 
hyoscyamin  is  invaluable  in  some  acute  cases  of  excitement, 
where  the  assistance  at  hand  is  insufficient  to  prevent  violence 
on  the  part  of  the  patient,  or  when  it  is  necessary  to  move  a 
person  in  a  condition  of  mania  into  some  institution  or  home. 

Care  must  be  exercised  when  a  patient  is  taking  hyoscin, 
and  if  the  doses  are  at  all  large  he  should  be  kept  in  bed. 

Bromide  of  potassium  is  useful  in  some  forms  of  insanity, 
especially  where  there  is  restlessness  with  depression.  The 
dose  has  to  be  a  large  one.  If  sixty  grains  are  administered 
three  or  four  times  a  day,  a  patient  may  sleep  peacefully  for 
many  hours  ;  he  should  be  roused  for  food  at  periodic  intervals. 
Its  effect  may  be  kept  up  for  days  with  perfect  safety.  It 
should  always  be  administered  in  plenty  of  water. 

The  principle  of  drugging  violent  and  excited  patients  is  to 
be  deprecated,  unless  they  are  confirmed  dements,  in  which  case 
no  harm  can  be  done  to  their  nerve-cells  ;  but  other  methods 
of  restraint,  such  as  seclusion,  are  preferable.  Various  hyp- 
notics are  fully  described  in  the  chapter  on  Sleeplessness,  and 
in  the  short  paragraph  on  treatment  the  hj^Dnotics  appropriate 
to  that  disorder  are  named  under  each  form  of  mental  disorder. 

Baths. — The  value  of  baths  in  the  treatment  of  mental 
disease  is  not  fully  appreciated  in  this  country.     Very  few 


474  PSYCHOLOGICAL  MEDICINE 

institutions  are  proiDeiiy  equipped  with  a  full  complement  of 
different  kinds  of  baths,  each  of  which  has  its  place  m  the 
treatment  of  various  diseases.  AA'e  know  that  the  action  of 
the  skin  is  deficient  m  many  forms  of  insanity,  and  yet  we 
neglect  to  benefit  by  this  knowledge,  for  we  fail  to  employ 
baths  as  much  as  we  should. 

If  there  is  any  truth  in  the  belief  that  auto-intoxication  plays 
an  important  part  in  the  production  of  mental  disorder,  surely 
it  is  "^Tong  not  to  try  to  remove  some  of  the  poisonous  sub- 
stances by  the  constant  cleansing  of  the  skin.  The  sm-face 
of  the  body  is  so  large  that  if  the  pores  are  kept  free  and  the 
sweat  glands  active,  they  must  in  no  small  degree  assist  the 
kidneys  and  intestines  in  their  work  of  removing  toxic  material. 
There  is  a  peculiar  odour  about  many  of  the  insane,  which  is 
readily  removed  by  prolonged  baths,  proving  that  the  constant 
apphcation  of  water  does  cleanse  the  sebaceous  glands. 

Cold  baths,  when  followed  by  a  proper  reaction,  serve  as 
a  general  tonic.  The  immediate  effect  of  a  warm  bath  is  to 
diminish  the  arterial  tension,  but  if  the  bath  is  prolonged  for 
some  hours  the  general  blood-pressure  is  raised.  For  this 
reason  prolonged  baths  are  often  very  beneficial  in  the  treat- 
ment of  acute  mania  and  other  forms  of  excitement.  The 
bath  probabty  also  acts  in  a  mechanical  way,  for  the  weight 
of  the  water  upon  the  abdomen  causes  a  constriction  of  the 
vessels  in  the  splanchnic  area. 

A  prolonged  bath  can  be  given  m  an  ordinary  bath,  as 
the  Hd  can  be  fitted  in  such  a  way  that  the  whole  bath  can 
be  covered,  except  a  small  portion  which  is  left  for  the 
patient's  neck.  The  water  should  be  about  the  body  heat  to 
start  with,  and  it  will  be  found  to  dimmish  graduaUy  m  tem- 
peratm'e  until  after  six  or  seven  hours  when  it  is  about  92°  P. 
When  these  baths  are  given  the  patient  should  be  in  the  v/ater 
about  half  an  horn*  the  first  day,  and  the  length  of  time  should 
be  daily  increased  until  it  reaches  a  maximum  of  about  six  or 
seven  hours.  At  this  Hmit  they  should  remain  for  a  few  days, 
and  then  it  should  be  slowly  decreased.  The  treatment,  if 
proving  beneficial,  may  be  carried  out  for  several  weeks.  The 
patient  should  never  be  left  unattended,  and  food  should  be 
administered  at  regular  intervals. 

Cold  and  tepid  shower  baths  and  spinal  douches  are  also 


TREATMENT  475 

useful  in  some  cases.  Turkish  baths  and  vapour  baths  have 
also  been  used  mth  success  in  the  treatment  of  mental  disease. 
Some  forms  of  stupor  are  greatly  benefited  by  a  course  of 
Turkish  baths.  Shower  baths  should  never  be  given  as  a 
punishment.  Certain  patients,  who  pass  their  excreta  under 
them,  either  from  lack  of  energy  to  go  to  the  lavatory  or  in 
order  to  annoy  the  nurses,  should  be  cleansed  in  cold  water 
in  the  bath-room,  provided  they  do  not  become  blue  and  cold 
during  the  process.  In  conclusion,  baths  will  be  found  most 
useful  in  the  treatment  of  insomnia  and  general  restlessness. 
Some  authorities  recommend  the  employment  of  wet  packs  in 
these  cases. 

Electrotherapy. — Electricity  gives  varying  results  in  the 
treatment  of  insanity.  The  faradaic  current  is  employed 
with  benefit  in  some  of  the  true  hysterical  cases  and  is  also 
beneficial  in  certain  stuporose  patients.  Electrical  currents 
of  high  frequency  are  said  to  lower  the  blood-pressure  and 
may  prove  useful  in  the  treatment  of  melancholia. 

Hsrpnotism. — Yoisin  claims  to  have  cured  many  patients 
suffering  from  insanity  by  hj^pnotic  suggestion,  and  successful 
results  are  said  to  have  been  obtained  by  other  continental 
authorities.  In  England  and  Scotland  the  employment  of 
hypnotism  m  the  treatment  of  mental  disorder  has  been  far 
from  encouraging,  and  even  experienced  physicians  have  failed 
to  obtain  really  satisfactory  results  On  the  other  hand, 
hypnosis  has  proved  of  great  value  in  overcoming  some  per- 
sistent forms  of  insomnia,  and  in  this  way  it  can  claim  to  be 
of  use  in  the  prophylactic  treatment  of  insanity.  Hypnotic 
suggestion  is  reported  to  have  cm^ed  many  patients  suffering 
from  drug  habits,  such  as  dipsomania,  morphinism,  and  the 
like,  and  has  also  shown  itself  to  be  useful  in  correcting  other 
vicious  habits. 

There  is  no  doubt  that  the  difficulty  of  obtainmg  the  atten- 
tion of  an  insane  person  is  the  reason  why  the  results  obtained 
from  hypnosis  are  so  unsatisfactory.  A  high  degree  of  concen- 
tration of  attention  is  required,  and  this  the  insane  man  cannot 
give.  The  time  required  for  the  induction  of  deep  hypnosis 
varies  greatly  in  different  persons,  and  not  uncommonly  it  is 
necessary  to  make  sixty  or  seventy  attempts  before  a  suc- 
cessful result  is  obtained. 


476  PSYCHOLOGICAL  MEDICINE 

Convalescence. — One  of  the  greatest  trials  a  physician  has 
to  encounter  is  the  tendency  of  relatives  to  remove  an  insane 
patient  as  soon  as  the  acute  symptoms  of  the  illness  have 
passed  off  and  just  as  convalescence  is  beginning.  The  layman 
believes  that  he  can  complete  the  cure  and  that  further 
residence  in  an  asylum  is  bad  for  the  patient,  and  there  are 
several  reasons  why  he  comes  to  this  conclusion.  Many 
persons  believe  that  association  with  the  insane  is  bad  and 
may  produce  mental  disorder.  There  is  no  such  thing  as 
contact  insanity  in  this  sense  ;  indeed,  many  of  the  insane 
can  help  each  other  on  the  road  to  recovery.  From  experience 
it  is  beyond  doubt  that  most  persons  suffering  from  mental 
disorder  are  happier  with  others  similarly  affected  than  in 
their  ovm  homes.  The  fact  that  a  man  has  so  far  progressed 
towards  recovery  that  he  is  considered  well  enough  to  be 
removed  shows  that  the  association  v>'ith  other  insane  persons 
has  not  been  harmful  to  him. 

Another  pomt  is  that  many  of  the  msane  appear  much  better 
in  institutions  than  thej  really  are,  and  relatives  begin  to 
think  that  they  made  a  mistake  in  sending  the  patient  away 
fi'om  home.  Nevertheless,  if  they  remove  him,  they  will 
soon  find  out  their  mistake,  as  all  the  acute  symptoms  quickly 
retmii. 

The  longer  and  more  quietly  convalescence  is  allowed 
to  progress,  the  better  and  more  permanent  the  recovery. 
There  is  nothing  that  will  cause  a  relapse  more  readily  than 
a  premature  removal  from  care,  whether  this  is  being  effected 
in  a  private  house  or  in  an  asylum.  Eelatives  should  fully 
consider  the  seriousness  of  the  step  before  carrying  it  into 
execution.  Patients  will  often  beg  to  be  taken  away,  saying 
that  if  only  they  were  removed  home,  or  to  some  other  place, 
they  would  soon  be  well.  It  is  very  wTong  to  submit  to  dicta- 
tion by  the  patient,  and  to  assent  to  his  request  is  not  true 
kindness,  for  it  risks  his  chance  of  recovery. 

It  is  grievous  to  think  of  the  number  of  persons  who  become 
chronically  insane  owing  to  ignorance  and  want  of  decision 
on  the  part  of  their  relatives.  If  a  phthisical  patient  were 
told  by  his  medical  attendant  that  he  ought  to  live  in  a  certain 
place  or  follow  a  certain  treatment,  all  the  relatives  of  that 
man  would  do  thok  best  to  see  that  these  instructions  were 


TREATMENT  477 

carried  out.  Why  should  they  be  unwihing  to  obey  the 
advice  of  the  same  physician  when  the  malady  is  a  mental 
and  not  a  physical  one  ?  The  reason  is  not  far  to  seek  ;  it  is 
because  everybody  believes  that  he  knows  insanity  when  he 
sees  it,  and  unless  the  man  is  breaking  up  the  home,  singing, 
shouting,  and  hostile  to  his  neighbours,  in  their  estimation  he 
is  not  insane  and  should  not  be  deprived  of  his  liberty.  It 
is  sad  to  think  that  the  patient  must  suffer  for  the  folly  of  his 
friends,  and  it  is  incumbent  upon  the  physician  to  state  clearly 
the  risks  that  are  being  run,  and  to  impress  upon  the  relatives 
the  responsibility  that  lies  upon  them. 

To  conclude,  the  physician  who  undertakes  the  treatment 
of  the  mentally  afflicted  and  carries  it  out  with  thoroughness 
and  zeal,  will  be  amply  rewarded.  A  visit  to  one  of  our  large 
county  asylums  may  take  the  heart  out  of  the  most 
optimistic,  for  in  truth  they  are  filled  with  degenerate 
humanity.  Such  a  sight  may  be  depressing,  but  medical 
science  would  not  stand  where  it  does  to  day  if  our  prede- 
cessors had  despaired  in  the  face  of  a  seemingly  overwhelming 
task. 

Much  more  can  be  done  in  the  way  of  prophylaxis  than 
has  been  attempted  in  the  past,  if  only  the  public  will  awaken 
to  the  fact  and  take  a  reasonable  view  of  msanity.  Again, 
the  early  treatment  of  slight  forms  of  mental  disorder  would 
prevent  many  persons  from  becoming  definitely  insane. 
Attention  to  these  two  points  alone  would  go  far  towards 
reducing  the  number  of  fi'esh  cases  of  insanity. 

Notwithstanding  the  excellent  work  which  has  akeady 
been  done  in  psychological  medicine,  we  stand  but  upon  the 
threshold,  and  there  is  no  branch  of  medicine  which  affords 
greater  potentialities  for  the  student. 


INDEX 


Aboulia,  70 

Accident,  as  a  cause  of  general  para- 
lysis, 224 
Accusations,  false,  80,  182,  365,  367 
Action,  11 

Acute  delirious  mania,  101,  105,  113 
Acute  hallucinatory  insanity,  260 
iEsthetic  sentiment,  disorders  of,  73 
Aiiection,  3 
Ageusia,  55 

Agnostic  :perscveration,  50 
Agoraphobia,  295 
Albuminuria,  87 

Alcohol,  as  a  cause  of  insanity,  33 
Alcohol  in  crime,  386 
Alcoholic  insanity,  chronic,  204 
diagnosis  of,  208 
mental  symptoms  of,  204 
pathology  and  morbid  anatomy 

of,  210 
physical  symptoms  of,  207 
prognosis  of,  210 
treatment  of,  213 
Alcoholism,  196 
acute,  198 
chronic,  202 
delirium  tremens,  199 
mania-a-potu,  201 
varieties  of,  198 
dipsomania,  210 
Alternating  insanity,  328,  329 
Amnesia,  65 

effect  on  testamentary  capacity, 
206 
Anaesthesia,  48 
Analgesia,  48 
Anergic  stupor,  134,  136 
Anomalies  of  the  ear,  89 
Anxiety  neurosis,  260 
Aphasia,   testamentary   capacity   in, 

399 
Apoplectiform    seizures    in     general 

paralysis,  235 
Apraxia,  69 
Arterial  tension  in  the  insane,  81 


Arteriopathic  dementia,  189 

diagnosis  of,  192 

j)athology  and  morbid  anatomy 
of,  193 

physical  symptoms  of,  191 

prognosis  of,  193 
Atavism,  27 
Association  of  ideas,  5 
Association,  disorders  of,  65 
Attention,  3 

disorders  of,  62 
Auditory  hallucinations,  54 
Aura,  epileptic,  271 
Automatic  obedience,  69,  159 
Automatism,  post-epileptic,  268 


Baths,  473 

Bed-sores,  88 

BeUef,  13 

Blood,  83 

Blood-pressure  in  the  insane,  81 

Boarders,  voluntary,  442 

Bones,  friability  of,  88 

Boulimia,  48 

Brain,  tumours  of,  172 

Brain  hypochondriasis,  122 

Brain  syphilis,  336 

Breathing  exercises,  452 


Case-taking,  412 
Catamenia,  87 
Catatonia,  138 

course  of,  139 

mental  symptoms  of,  138 

physical  symptoms  of,  139 

prognosis  of,  140 

treatment  of,  140 
Catatonic  form  of  dementia  prsecox, 

160 
Causation  of  insamty,  26 
Cerebro-spinal  fluid  in  general  para- 
lysis of  the  insane,  250 
Certification  of  the  insane,  417,  442 


480 


INDEX 


Chorea  and  insanity,  317 
Circular  insanity,  100,  117 
Ci-vil  liability  of  the  insane,  388 
Classification  of  insanity,  39 
Climacteric  insanity,  181 

setiology  of,  181 

mental  symptoms  of,  182 

pathology  and  morbid  anatomy 
of,  185 

prodromata  of,  182 

prognosis  of,  184 

treatment  of,  185 
Cocainism,  218 
Cognition,  10 
Collapse  delirium,  260 
Communicated  insanity,  151 
Conation,  4 

Confusional  insamty,  acute,  260 
Consciousness,  disorders  of,  60 

self,  14 
Constipation,  88 

treatment  of,  450 
Convalescence,  476 
Convulsions    as    a    cause    of   idiocv, 

342 
Convulsions  in  general  paralysis,  234 
Corpus  caUosum,  tumours  of,  172 
Correspondence,  467 

regulations  regarding,  469 
Cousins,  marriage  of,  28 
Cranial  deformities,  91 
Cretinism,  325 
Crime  and  insanity,  380 


DeUrium,  acute  bacillary,  110 
Delirium  tremens,  199 
Delusional  insanity  (cluronic),  141 

ffitiology  of,  145 

course  of,  153 

diagnosis  of,  153 

mental  symptoms  of,  146 

pathology  and  morbid  anatomy 
of,  154 

physical  syinptoms  of,  152 

prognosis  of,  154 

treatment  of,  154 

varieties  of,  145 
Delusions,  58 

classification  of,  60 
Dementia,  acute,  133 
Dementia,  arteriopathic,  189 
Dementia,  organic,  170 
Dementia  paralytica,  222 
Dementia  paranoides,  158,  161 
Dementia  prajcox,  156 

aetiology  of,  157 

course  of,  162 

diagnosis  of,  163 

mental  symptoms  of,  158 


Dementia  prsecox, 

phj'sical  symptoms  of,  162 

prognosis  of,  164 

treatment  of,  165 

varieties  of,  157 
Dementia,  primary,  133 
Dementia,  secondary,  166 

aetiology  of,  167 

mental  symptoms  of,  167 

morbid  anatomy  changes  in,  169 

phj'sical  symptoms  of,  169 
^  treatment  of,  169 
Diabetes  and  insanity,  315 
Diathesis,  insane,  37 
Diet,  446 
Dipsomania,  210 
Doubt,  8,  13 
Dream  analysis,  464 

states,  17 
Dreams,  464 

condensation  in,  464 

displacement  in,  464 

dramatisation  in,  464 

sj^mbolisation  in,  464 
Drugs  in  treatment,  471 

Ear,  deformities  of,  89 
Echolalia,  94,  139,  158,  159 
Echopraxia,  69,  158 
Eclampsic  idiocy,  354,  360 
Education  of  idiots,  361 

of  neurotic  children,  437 

of  the  young,  436,  438 
Effort,  feeling  of,  4 
Electro-therapy,  475 
Emotions,  8 

disturbances  of,  68 
Encephalitis,  chronic  diffuse,  170 
Epilepsy  and  insanity,  265 

diagnosis  of,  272 

pathology  and  morbid  anatomy 
of,  273 

phj'sical  symptoms  of,  271 

treatment  of,  276 

varieties  of,  266 
Epileptic  automatism,  268 
Epileptic  conditions  in  general  para- 
lysis, 234 
Epileptic  idiocy,  355,  360 
Exaltation,  71 
Exercise,  physical,  451 
Exhaustion  psychoses,  254,  260 
Exophthalmic  goitre,  324 
Expression,  95 
Eyes,  movement  of,  95 

False  accusations  in  insanity,  80,  182, 
365,  367 
in  epilepsy,  267 


INDEX 


481 


Fatigue  states,  78 

Fears,  morbid,  295 

Feeding,  forcible,  447 

Feigned  insanity,  373 

Fidgets,  12 

Flexibilitas  cerea,  135,  139,  158 

Folie  a  deux,  151 

Folie  circulaire,  100,  117 

FoUe  de  doubte,  9 

Forcible  feeding,  447 

Free  association,  465 

Fright  to  mother,  as  a  cause  of  idiocy, 

342 
Frontal  lobe,  tumours  of,  172 

Gastro-intestinal  hypochondriasis,  122 
General  hypochondriasis,  123 
General  paralysis  of  the  insane,  222 

setiology  of,  222 

cerebro-spinal  fluid  in,  250 

course  of,  239 

diagnosis  of,  240 

mental  symptoms  of,  226 

pathology  and  morbid  anatomy 
of,  243 

physical  symptoms  of,  231 

prodromata  of,  224 

remissions  in,  240 

treatment  of,  252 

varieties  of,  224 

juvenile,  238 
Genetous  idiocy,  353,  359 
Glycosuria  and  insanity,  315 
Gout  and  insanity,  328 
Gustatory  hallucinations,  54 

Habit,  6,  36,  72 
Hsematoma  auris,  88 
Hsematoporphyrinuria,  410 
Hallucinations,  49,  50 

in  hypnagogic  states,  53 

psycho -motor,  55 

reflex,  of  Kahlbaum,  58 

theories  as  to  causation  of,  56 
Hallucinatory  insanity,  acute,  260 
Handwriting  of  the  insane,  96 

in  general  paralysis,  233 
Head  injury  as  cause  of  general  para- 
lysis, 224 
Heart  and  vascular  system,  81 
Heart  disease  and  insanity,  331 
Hebephrenia,  159,  160 
Heredity,  27 
Homicide,  77,  154,  268,  459 

prevention  of,  459 
Huntington's  chorea,  319 
Hydrocephalic  idiocy,  354,  359 
Hyoscin,  411,  473 
Hyperaesthesia,  48 


Hyperattention,  62 

Hypergeusia,  55 

Hypermnesia,  65,  67 

Hypertrophic  idiocy,  354,  360 

Hypnosis,  467,  475 

Hypnotics,  407 

Hypochondriacal  melancholia,  121 

Hypochondriasis,  123 

Hypogeusia,  55 

Hysteria  and  insanity,  277 

Hystero -epilepsy,  283 

Ideas,  4 

association  of,  5 

flight  of,  103 
Ideational  inertia,  50 
Idiocy  and  imbecility,  340 

setiology  of,  341 

diagnosis  of,  356 

from  deprivation  of  senses,  356 

general    pathology    and    morbid 
anatomy  of,  357 

mental  phenomenain,  343 

physical  symptoms  of,  349 

treatment  of,  360 

varieties  of,  352 
Illusions,  49,  50 
Imagination,  11 
Imbecility,  340 

moral,  364 
Imperative  ideas,  ^93 
Imperception,  49 
Impotence,  ideas  of,  122 
Impulse,  12 
Impulsive  acts,  71 
Inattention,  62 
Incoherrnce,  93 
Infanticide,  dangers  of,  175 
Influenza  and  insanity,  315 
Inheritance,  laws  of,  27,  223 
Injuries,  cause  of  general  paralysis,  224 
Inquisitiveness,  296 
Insane  ear,  89 
Insanity,  causation  of,  26 

classification  of,  39 

what  is,  19 
Insanity  and  physical  diseases,  312 
Insomnia,  400 
Instinct,  9 

Institutions  for  the  insane,  442 
Inter-actiouism,  2 

Intestinal  infection,  treatment  of,  451 
Intoxication  psychoses,  196 
Irritability,  79 

Jealousy,  80 
Judgment,  12 
Judicial  authority,  420 
Juvenile  general  paralysis,  238 

31 


482 


INDEX 


Kinsesthesia,  14,  20 
Kleptomania,  71 
Korsakow's  Disease,  213 
Krapelin's   classification  of  insanity, 
40 


Lactation,  insanity  of,  177,  178,  179 
Law  in  relation  to  insanity,  380 
Lead  poisoning  and  insanity,  220 
Legal  responsibility,  380 
Letter-writing,  467 

regulations  regarding,  469 
Leucocytosis,  83 
Licensed  houses,  443 
Light  phonisms,  52 
Limbs,  deformities  of,  93 
Lochia  in  puerperal  insanity,  178,  179 
Locomotor  ataxy  and   general   para- 
lysis, 242 
Lucid  interval,  396 
Lumbar  pimcture,  250 
Luminal,  411 


Malaria,  332 
Malingering,  373 
Mania,  99 

aetiology  of,  99 

course  of,  107 

diagnosis  of,  109 

mental  symptoms  of,  102 

pathology  and  morbid  anatomy 
of,  110 

physical  symptoms  of,  106 

prodromata  of,  101 

prognosis  of,  110 

varieties  of,  100,  101 
Mania-a-potu,  201 
Maniacal-depressive      insanity,      101, 

104,  117,  123 
Marriage  contracts  by  insane  persons, 

389 
Marriage  of  first  cousins,  28 
Masked  epilepsy,  266,  267 
Massage,  446 
Masturbation,  34,  73 
Mechanical  restraint,  454 

regulations  regarding,  454 
Medical    certificate    statutory    form, 

430 
Melancholia,  115 

aetiology  of,  116 

course  of,  126 

diagnosis  of,  126 

mental  symptoms  of,  118 

pathology  and  morbid  anatomy 
of,  128 

physical  symptoms  of,  124 


Melancholia 

prodromata  of,  118 

prognosis  of,  127 

treatment  of,  129 

varieties  of,  117 
Memory,  10 

disorders  of,  65 
Meningo^encephalitis,  chronic,  244 
Menstruation,  87 
Mental  Deficiency  Act,  364,  368 
Metabolism,  29 

Microcephalic  idiocy,  353,  359 
ilicrokinesis,  12 
Mirror  writing,  98,  352 
Mitral  disease  and  insanity,  331 
MongoUan  idiocy,  353 
Monomania,  144 
Moral  imbecility,  364 

diagnosis  of,  366 
Moral  treatment  of  insanity,  459 
Morphinism,  214 
Motor  apraxia,  69 
Movements,  11,  70 

in  mania,  106 
Muscular  element  of  thought,  64 
Mutilation  of  self  in  hysteria,  280 
Mutism,  93,  139 
Myxoedema,  320 


Nasal  tube,  feeding  bv,  448 
Negati-dsm,  69,  138,  160 
Nerve  exhaustion,  254 
Neurasthenia  and  nerve  exhaustion, 
254 

aetiology  of,  254 

diagnosis  of,  258 

mental  symptoms  of,  255 

physical  symptoms  of,  256 

prognosis  of,  258 

treatment  of,  259 
Neuroses,  general,  265 

due  to  strain  of  war,  300 
Neurotic  children,  education  of,  437 
Night  terrors,  402 
Nurses,  special  duties  of,  470 
Nutritional  changes  in  insanity,  88 


Object-consciousness,  14,  63 

Obsessions,  293 

Occupation,  462 

Odour  photisms,  53 

OEsophageal  tube,  feeding  by,  449 

Olfactory  hallucinations,  55 

Onanism,  34,  73 

Opium,  407 

Organic  dementia,  170 

Othsematoma,  88 

Over- work,  31 


INDEX 


483 


Pain  photisms,  53 
Palate,  deformities  of,  92 
Parsesthesia,  48 
Parageusia,  55 
Paramnesia,  65,  68 
Paranoia,  141 

varieties  of,  145 
Paranoid    form,    dementia    prsecox, 

157,  161,  168 
Parole,  470 
Passion,  8 
Perception,  4 

disorders  of,  49 
Perspiration,  86 
Phonisms,  52 
Photisms,  52 

Phthisis  and  insanity,  312 
Physical  disease  and  insanity,  312 
Pituitary  body,  tumours  of,  172 
Plumbism,  220 
Polyneuritic  psychosis,  213 
Porencephaly,  358 
Post-epileptic  automatism,  268 
Post-epileptic  mental  disorders,  268 
Posture,  96 

Pre-epileptic  insanity,  267 
Pregnancy,  insanity  of,  173,  177,  178, 

179 
Premature  labour,  induction  of,  175 
Primary  dementia,  133 
Private  asylums,  444 
Prolonged  baths,  473 
Psychasthenia,  293 

aetiology  of,  294 

mental  systems  of,  294 

treatment  of,  299 

varieties  of,  294 
Psycho-analysis,  463 
Pyschology,  normal,  1 
Psycho-motor  hallucinations,  55 
Psycho -neuroses,  465 

due  to  strain  of  war,  300 
Psycho-therapeutics,  462 
Puerperal  insanities,  174 

aetiology  of,  173 

course  of,  178 

mental  symptoms  of,  175 

pat  ology  and  morbid  anatomy 
of,  180 

physical  symptoms  of,  177 

prognosis  of,  179 

varieties  of,  174 
Pyromania,  71,  367 


Reaction  times,  15,  465 
Reasoning,  12 
Reception  order,  420 
Reception    orders    by   two    Commis- 
sioners, 426 


Recognition,  10 

Rectal  feeding,  448 

Recurrent  insanity,  100,  117,  123 

Re-education,  467 

Reflex  disorders,  94 

Reflex   hallucinations    of  Kahlbaum, 

58 
Relation,  13 

Relaxation  exercises,  451 
Religion,  as  cause  of  insanity,  32 
Religious  services,  470 
Remissions  in  general  paralysis,  243 
Respiratory  hallucinations,  86 
Respiratory  system,  86 
Responsibility  in  the  insane — 
civil,  388 
criminal,  374 
Rest  in  treatment,  446 
Restlessness,  79 
Restraint,  mechanical,  454 
Rheumatic  fever  and  insanity,  323 
Rhythm,  5 


Salivation,  86 

Sanguinity,  law  of,  28 

Sclerosis  of  brain  in  idiocy,  358 

Seclusion,  452 

Secretory  disorders  in  the  insane,  86 

Seizures  in  general  paralysis,  234 

Self -consciousness,  14,  61 

Self -mutilation  in  hysteria,  280 

Senile  insanity,  186 

medico-legal  aspect,  188 

mental  symptoms  of,  187 

pathology  and  morbid  anatomy 
of,  193 

physical  symptoms  of,  191 

prognosis  of,  193 

varieties  of,  187 
Sensation,  2 

disorders  of,  48 

secondary,  52 
Sensory  apraxia,  69 
Sentiment,  8 

Sex  in  aetiology  of  insanity,  34 
Sexual  excess,  34 
Sexual  hypochondriasis,  122 
Sexual  malpractices,  73 
Shell-shock,  301 
Single  care,  444 
Sleeplessness,  400 
Somnambulism,  402 
Sound  photisms,  52 
Speech,  disorders  of.  93 

in  idiots,  351 
Stammering,  93 

Stereotyped  movements,  69,  138 
Sterognosis,  5 
Stigmata  of  degeneration,  89,  349 


484 


INDEX 


Strait-waistcoat,  455 
Stupor,  133 

Eetiology  of,  133 

course  of,  137 

diagnosis  of,  137 

mental  symptoms  of,  133 

pathology  and  morbid  anatomy 
of,  138 

physical  symptoms  of,  135 

prognosis  of,  137 

treatment  of,  137 

varieties  of,  133 
Subject  consciousness,  13,  63 
Suggestion,  467 
Suicide,  74,  416 

prevention  of,  457 
Sulphonal  poisoning,  410 
Summary  reception  orders,  421 
Sunstroke  and  insanity,  331 
Sunstroke    as    a    cause    of    general 

paralysis,  224 
Symbolism,  151 
Symptomatology,  general,  45 
Syphilis  as  a    ause  of  insanity,  34 

of  general  paralysis,  223 

of  idiocy,  341 
Syphilis,  congenital,  334 
SypMlis  and  insanitv.  332 
Syphihtic  idiocy,  356,  360 
SypbiUtic  insanity,  diagnosis  of,  336 

prognosis  of,  336 

morbid  anatomy  of,  336 

treatment  of,  338 
Syphilophobia,  333 


Tabes  dorsalis  and  general  paralysis, 

242 
Tabetic    form    of    general    paralysis, 

230,  233 


Tactual  hallucinations,  55 
Taste  photisms,  52 
Temperament,  36 
Temperature,  94 
Testamentary  capacity,  391 
Therapeutic  conTersation,  463 
Thought,  muscular  element  of,  64 
Traumatic  idiocy,  355 

neuroses,  287 
Travelling,  439,  440 
Treatment  of  insanity,  433 

preventive,  of  insanity,  434 
Trional,  411 
Trophic  disorders,  88 
Tumours  of  brain  andinsanity,170,172 


Unsoundness  of  mind,  442 

Urgencv  certificate,  statutorv  form, 

430   ' 
Urgency  orders  and  certificates,  417 
Urine  in  the  insane,  87 


Vascular  system,  81 
Verbigeration,  94,  139 
Violence,  treatment  of,  452 
Visiting  the  insane,  469 
Visual  hallucinations,  54 
Volition,  12 

disorders  of,  69 
Voluntary  boarder,  442 


War,  neuroses   and  psvcho-neuroses 

in,  300 
Weber's  law,  3 
WiU,  disorders  of,  69 
"Wills,  making  of,  391 
Word  association.  465 


AT  THE  BALLANTYNE  PRESS 

PRINTED  BV  SPOTTISWOODE,  BALLANTYNE  AVD  CO.  LTT. 

COLCHESTER,  LONDON  AND  ETON,  ENGLAND 


COLUMBIA   UNIVERSITY   LIBRARIES 

This  book  is  due  on  the  date  indicated  below,  or  at  the 
expiration  of  a  definite  period  after  the  date  of  borrowing,  as 
provided  by  the  library  rules  or  by  special  arrangement  with 
the  Librarian  in  charge. 

DATE  BORROWED 

DATE  DUE 

DATE   BORROWED 

DATE   DUE 

ms>o    -o/ic 

i 

1 

C28(546)M25 

C84 

IRC341  ^^„ 

lOraig 

Psychological  medicine. 


